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Health and Wellness

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Health and Wellness in Native North America

It is true that many of the old ways have been lost. But just as the rains restore the earth after a drought, so the power of the Great Mystery will restore the way and give it new life. We ask that this happen not just for the Red People, but for all people, that they all might live. Black Elk, Oglala, Sioux

Contemporary health status of American Indians can be best viewed through the lens of various federal policies enacted over the past 500 years. These policies were developed largely in response to dramatic population losses among the indigenous peoples of America, resulting from genocidal actions of military campaigns, the lack of immunity to the diseases that accompanied European colonizers, and the assimilation efforts that destroyed tribal structures and wellness practices. Medical services were first coordinated through army physicians in the Department of War in an effort to control the spread of diseases from early reservation sites placed on or near military forts. By the twentieth century, the rapid decline of the Indigenous population, documented by the “Meriam Report” of 19281 prompted new assimilation efforts to save the first Americans. Healthcare services were re-coordinated within the Bureau of Indian Affairs and then into the Public Health Service, finally resting within the Federal Indian Health Service (IHS). Assimilation policies, however, proved to be highly destructive resulting in the loss of languages, culture and social structures. Indigenous wellness practices were threatened and many healing practices were forced underground and many were lost. The influence of Western cultures changed the health and welfare of American Indians prompting a transition from indigenous wellness to bouts of deadly acute illnesses (e.g. small pox, whooping cough, influenza and tuberculosis) followed by widespread chronic conditions experienced today, such as type 2 diabetes, cancers and substance abuse caused largely by behavioral and environmental influences. More recent federal “self-determination” policies enacted in the 1970s created opportunities for tribes to assume the delivery of healthcare services to their members. The future status of health and wellness among American indigenous populations requires an understanding of the inherited damage resulting from various federal policies along with attention to the strengthening of tribal wellness practices.

Wellness and American Indians

Wellness is an important facet of health and welfare in American Indian cultures. The concept of wellness encompasses more than just the absence of disease; it is the balance of one’s body, mind and environment that together maintains good health status2,3. The interconnectedness of all aspects of life, along with everything in the world is central to many indigenous cultures. To be well, one must live in harmony and balance all parts of life, including the physical, mental, emotional and spiritual well-being as it is interconnected with the environment.4 Poor health can result from a failure in any or all of these parts.

A major part of wellness practices is activities that protect, prevent and treat illness, which can include indigenous ceremonies, songs and medicines. Although not all tribes embraced the same ceremonial practices, all held illness beliefs and wellness concepts that dictated healthy lifestyles of individuals and communities. Illness was seen as a breach of the wellness practices and a disruption in living in balance.

Diseases and illness common among European countries was initially unknown among indigenous America – until the arrival of the colonists. Early physicians, traders, and explorers remarked about the extraordinarily good health of the Natives, noting that Native peoples were clean, good looking, without apparent illness, and peaceful.5 Indigenous groups were known to use medicine from plants such as dogwood for reducing fevers and sassafras, fern, goldenrod, and prickly pear teas for use as a diuretic. Heat treatment, both as sweat baths and herbal packs were used to treat pain, arthritis and respiratory disorders. Massages, bloodletting, and the lancing of boils were common. And the burning of bedding and infected items belonging to the sick or recently deceased was a ritualistic practice that effectively sanitized materials. Despite living a relatively healthy lifestyle, American indigenous groups were unprepared for the onslaught of diseases that quickly eradicated tribal groups and whole communities. These diseases were not treatable with indigenous medicines. A new approach was needed to manage the growing health threats and save the lives of American Indians.

Isolated Medical Care

With the arrival of the Europeans came the epidemic of diseases that led to the death of hundreds of thousands of Indians. At the turn of this century, the population of American Indians was reduced to a paltry 250,000 to 125,000 in the contiguous United States - a significant reduction that threatened the extinction of all tribes6,7,8,9. Whole tribes became extinct, as they were ill prepared to fight off the diseases and illnesses brought over with the early settlers. Europeans had built up a natural immunity through years of prior exposure; however, Indians had no natural immunity to smallpox, measles, tuberculosis, or typhoid.

Diseases such as dysentery, widely reported among American Indians, were not effectively controlled until sanitation (clean water and food) was upgraded and waste materials removed from forced and guarded military encampments. Reports of rotting meat and bug-infested food supplies given out along with rank drinking water at the encampments contributed to poor sanitation environments10. In addition, the deliberate spread of infectious and deadly disease was documented. During the French and Indian War of 1756-1763, British military commanders advised that small-pox infected blankets be distributed among American Indian communities as a means to “Extirpate this Execrable Race”11,12. More than half of the Huron and Iroquois confederations were eliminated through small pox deaths13, and half of the Cherokees and Catawbas13, and two-thirds of the Omahas also fell to the disease14. The subsequent spreading of whooping cough, influenza, tuberculosis and pneumonia decimated the American Indian population and brought numerous tribes to the brink of extinction15, 16. Unfortunately, military physicians were not available to these communities.

As part of the federal government’s trust responsibility, treaty obligations and undertaking to “civilize” American Indian tribes, it assumed control over not only tribal physical assets such as land and natural resources but it also assumed responsibility for the healthcare of tribal members. As a result of tribes’ status as “domestic dependent nations,” the federal government began providing appropriations for health services. The first organized delivery of medical services to American Indians was provided by US army physicians up until the transfer of the Bureau of Indian Affairs from the Department of War to the Department of the Interior in 184917,18. Once contagious illnesses started to spread from isolated groups of American Indians garrisoned on or near military forts, army medical personnel responded by quarantining the infected/ill indigenous groups. These actions were not intended to cure or to save the lives of American Indians; rather, they were for the protection of the military families who resided at the forts19. Department of War physicians would periodically inspect, quarantine, and minimally treat the imprisoned Indian groups to control the spread of diseases from the reservation sites to military families and personnel.

Western Medical Care

Following the transfer of the Indian health responsibilities from the Department of War to the Department of the Interior, BIA agents became responsible for overseeing the delivery of medical services to the population of the Indian agencies. Problems continued to plague tribes. Few of the agencies had doctors and agents were not always responsive to the healthcare needs of their agency17,18. By the twentieth century, the rapid decline of the American Indian population documented by the “Meriam Report” of 19281, prompted new efforts in the form of assimilation policies designed to save the first Indigenous Americans. Medical services were re-coordinated within the Bureau of Indian Affairs and then in 1954 into the Public Health Service, finally resting within the Federal Indian Health Service. The provision of medical services was strictly of a Western nature, with no allowance for traditional indigenous medicines or ceremonies. These federal assimilation policies, however, proved to be as destructive as the spreading disease as they resulted in the weakening of the very core of American Indian culture disrupting social structures, eliminating languages, and enforcing Western illness beliefs, practices and lifestyles. Indigenous wellness healing practices were forced underground and many were lost. The influence of Western cultures through assimilation policies changed the health and welfare of American Indians prompting a transition from indigenous wellness to un-wellness caused largely by behavioral and environmental factors.

Assimilation policies, designed to education, train and absorb American Indians into Western society, had an enormous impact on the health and wellness of American Indians. Relocation of individuals and families from reservations to metropolitan areas, education and training in the ways of Western society (English language, dress and lifestyles, etc.), prohibition of indigenous spirituality and religious practices, and restriction of medical and healing practices removed access to traditional ways, learning, and practices over generations and re-socialized multiple generations of families to adopt Western lifestyles and medical practices. This adoption of Western ways resulted in behavioral and environmental problems as deadly - or perhaps even deadlier than the epidemic of acute diseases.

Institutionalized Care

The establishment of Indian Health Service (IHS) clinics and hospitals for federally recognized tribal members and their families distinguished between those groups who were eligible for medical care and those who were not eligible for care. Service eligibility and prioritized care was necessary as the US Congress allocated insufficient funds annually to meet the needs of all American Indians. Although Indian outpatient clinics were generally accessible to all residents of reservations-based clinics, those individuals residing in metropolitan areas and in rural areas with no Indian clinics often went without health care services. Although a few hospitals were located at strategic regional sites in the US, the type of medical services offered were limited as specialty services and surgical suites were lacking. It was the practice of the IHS to contract out to non-IHS physicians and facilities when healthcare services were not available at local reservations. Because this arrangement was costly, eligibility was prioritized to those individuals at threat of loss of sight, limb or life.

Western medical practices proved to be insufficient to prevent and treat the health problems brought about by the influences Western culture. Health problems shifted from acute problems (caused by such contagious viruses as small pox, influenza, and dysentery) to chronic health problems (type 2 diabetes, heart disease, cancer, and substance abuse) largely caused by the adaption of unhealthy lifestyles. The influence of Western cultures lead to health problems not easily treatable by the clinics and hospitals established on reservations.

Over the years, the health status of American Indians continued to fall well below that of the general population. Poor lifestyles and high-risk behaviors such as poor nutrition, sedentary lifestyles, smoking and substance abuse lead to critical health conditions such as obesity, heart disease, cancer and early death and disease20,21,22. More recently, type 2 diabetes, associated with obesity and low physical activity, has reached epidemic levels among American Indians contributing to loss of limbs, eyesight and death.

Today, American Indians are dying from chronic diseases that are largely attributed to environmental conditions and behavioral patterns. Acculturation and assimilation have contributed to the adoption of unhealthy behavioral patterns and habits such as smoking, drinking alcohol, and injuries and accidents. Behavioral influences have resulted in poverty, illness, and increased social disruption23,24.

Self Determination Impacting Health Care Services

The most seminal piece of federal legislative policy, the Indian Self-Determination and Education Assistance Act of 1975 (amended in 1988, 1990, and 1994) (Public Law 93-638), is meant to reverse the federal policies of past years by implementing self-determination policies25. This legislation was passed as a result of the governmental attempts to assimilate tribes by terminating the federal government’s responsibility to tribes coupled with aggressive Indian activism calling for a re-examination and reversal of the government policy. This new legislation encouraged "maximum Indian participation in the government and education of the Indian people"26. Tribes now had the authority to negotiate contracts, administer their own education and social service programs and participate on school boards. Later amendments provided direct grants to help tribes develop plans to assume responsibility for federal programs27, thus tribes have the ability to assume the implementation and management of various grants and programs previously headed by federal officials. These grants and programs include healthcare clinics, dental clinics, training and education programs, and support services28.

The Indian Self-Determination Act gave Indian tribes the ability to contracting directly with the IHS for the management and control of their own health programs. These contracted programs are commonly referred to as “638 contracts.” This legislation enabled Indians to become more actively involved in determining their own health care. American Indian access to health care and health insurance is the poorest as compared to all minority populations in the United States. American Indian and Alaska Natives under the age of 65 have the lowest rates of private health insurance coverage of any racial/ethnic group and 44% are uninsured or rely solely on IHS for medical services29.

The Self Determination Act essentially changed the policy of the Federal government in terms of management, planning, fiscal responsibility, and daily operations of health care services. Tribes were provided the opportunity to plan for, and to develop the healthcare system for their tribal members, albeit in the same structure, manner and environment as previously coordinated by the IHS. Tribal groups became active players in the healthcare delivery system. By assuming the management of the healthcare programs, tribes and tribal groups stepped forward to make a difference in the management and delivery of healthcare services.

Models of Health Care under Self-Determination Act

The Southcentral Foundation (SCF), an Alaska Native-owned, non-profit organization established in 1982 under the Cook Inlet Region, Inc., is an Alaskan Native regional corporation that serves 60,000 in the Anchorage area of 60 rural villages30,31,32,33. Prior to the creation of the SCF, regional healthcare services were provided under the IHS and locals sought these services as a “last resort” due to the perceived lack of quality care and services. Since its establishment under the Indian Self Determination and Education Assistance Act, giant leaps have been made in improving healthcare services and access the Indian population. Emergency room use and hospital admission has been reduced by over 50% while infant immunizations have risen to over 90% and the percentage of diabetics with blood sugar under control ranks in the top 10 percentile of the standard national benchmark. These accomplishments have come as a result of SCF’s model of care that treats patients as “customer-owners.” This has translated into a model that assigns small teams of healthcare providers and administrators to specific groups of patients; collecting and utilizing medical and financial performance data; planning consultations around the patient’s schedule and needs; building long-term relationships between the providers and patients; and being proactive with reaching out to patients. This patient-centered model of care has earned the SCF international and national recognition for its effective patient care and cost reduction.

Affordable Care Act

The recent passage of the Patient Protection and Affordable Care Act (ACA) in 2010 has significant implications for American Indian healthcare. Under the ACA, the Indian Health Care Improvement Act (IHCIA) is made permanent eliminating the yearly authorizations. While appropriations for Indian healthcare have never been entirely denied, this removes the uncertainty that often accompanies the political battles and national economic concerns that impact the budget. The ACA also calls for the creation of new programs to address disparities. The implementation of the ACA affects sovereign tribes and tribal members differently than the general American population. It provides more resources for diabetes prevention, treatment and control. Under the ACA Indians who use the exchanges to purchase healthcare and whose income is under 300 percent of the poverty line are not responsible for any cost-sharing (PL 111-148, Sec.2901(a); 25USC § 1623(a)).

Tribal Healthcare Programs

It took a short amount of time for tribes to submit the required form for assumption of the IHS healthcare service program. Training programs in administration, fiscal and legal management and accountability was coordinated for tribal staff. Although on-going management of the healthcare services remains within the tribal control once they undergo “638”, programs are required to provide the same level of care to eligible tribal members as previously experienced under the management of the federal government. Tribes are prohibited from using these funds for activities not related to the specific health service system that they are now managing.

Although many tribes have taken the opportunity offered to assume management of their area or region’s healthcare services, many tribes have opted not to enter into such “638” contracts. There are many downsides voiced by tribes that raise concerns over the risks associated with assuming such health service management. Firstly, once they assume the responsibility under a “638” contract, the tribe or tribal organization cannot back out of the contract and cannot “give back” the healthcare program to the federal government. Secondly, if faced with budgetary shortfalls (which is often the case when a tribal member experiences a serious health condition resulting from cancer, burns, car accident, etc.), the tribe cannot “borrow” funds from another IHS region – which has been the practice by the IHS over the years among their regional offices. And thirdly, the programs contracted under the “638” regulation has to be offered to the service population at the same level as that offered by the IHS. Thus the tribe cannot change the health service to emphasize traditional healers, native medicines, or other services outside the original service offering.

By contracting under the “638” regulation, tribes have indeed increased the employment opportunities for many of their members, however, they remain bound to hiring the original IHS providers as many of these clinics are located in isolated rural areas where recruiting of physicians, nurses, pharmacists, nutritionists, etc. can be difficult. Few American Indian health care professionals exist, forcing the clinics to hire the service providers who previously worked for the IHS.

The assumption of these clinics did not alleviate the age-old problem of access to health care services which remains a problem faced by the American Indian population. Small clinics located in rural areas are supported by few regional IHS hospitals, and together they provide much needed primary care, however, many problems facing American Indians are behavioral in nature and not amenable to simply a prescription or a pill. The complexity of the health problems experienced by American Indians has provided a challenge to tribes and the IHS alike, and these problems are not readily solvable or controlled through contemporary approaches.

Cultural Approaches to Health Care

Innovative approaches to health and wellness among American Indians care are currently being developed and implemented in Indian communities in an attempt reduce the health problem and their associated risks. The transition from acute to chronic health problems creates difficulty in prevention, treatment and control of the health problems because of their tie to behavioral risk factors. Current health statistics for American Indians suggest that heart disease, cancer, unintentional injuries, diabetes and stroke continue to be major health concerns along with high prevalence and risk factors for mental health concerns such as suicide, obesity, sudden infant death syndrome, and teen pregnancy34. These problems are not easily amenable within the current Indian healthcare system. The influence of culture on the constructs of illness results in unique illness beliefs and practices, and the impact of over 500 years of trauma on the emotional, mental, physical and spiritual well-being of the individual and the community has left an indelible wound. Incorporating community participation in health research, planning and program development helps to bring culture into the equation of health care services and strategies. Adopting culturally acceptable communication strategies (e.g., Talking Circles), and instituting cultural ways of dialogue and education through storytelling helps to merge the patient with the provider and also help to engage the community in participatory activities. This fosters wellness and address health promotion. Addressing chronic illness management, fostering cancer screening, suicide prevention, promotion of physical activity and healthy diet and lifestyle are but a few of the needs that require a blending of cultural understandings and behavioral science research in health promotion.

When coordinating healthcare services, there are several important reasons for engaging tribes in a collaborative partnership through the use of community-based partnerships. Western medical providers and researchers continue to be uninformed of American Indian cultural constructs of illnesses and the need to observe customs and traditions. For example, many providers are not aware of the ancient practice of returning body parts to the recently deceased so that the individual can pass into the next world whole35. In addition, communities may turn away from projects that center on sensitive topics, such as genetic tests or DNA analysis, as most tribes believe in origin stories that may tell of a different birth place of a tribe than what is reported in scientific studies36. Origin stories have been told and retold through generations, and are an important part of tribal traditions, ceremonies and myths, and their veracity may be brought into question by scientific reports. In addition, health services and programs on psychological issues, such as depression, mental illness, and the use of certain substances is controversial, as differences in definitions, the cultural constructs of measures, and the value-laden interpretation of results can be problematic37,38,39. Also, words such as “depressed” and “anxious” can be absent from some American Indian and Alaska Native languages38, making use of these words troubling and perhaps confusing.

As American Indians are a collective society whose decisions are made by the group or by elders, and not on an individual basis, this dynamic is an important cultural process to consider in designing health care programs. As often too little consideration is given to a culture that operates and views the world as a collective society. Communication techniques, such as, CBPR, is an excellent tool to both inform the community and to enable them a partnership role in research, intervention design and implementation of health and education programs.

Of equal importance is to the advancement of wellness in American Indian populations is discovering and utilizing outreach approaches that are most congruent with cultural values and patterns of communication and that allow language, history, world view to be captured. In this respect, health service methods that build theoretical models grounded in the world view of the population have been found to be crucial to health promotion intervention design. For example, it was found that women in the child bearing age or stage were more likely to be interfacing with the health delivery services and thus prime for Pap (Papanicolaou) cervical cancer screening and the prevention message given to the women needed to place emphasis on seeking the screening for her community and future generations40.

There are several recent programs that highlight innovative approaches to health and wellness among the American Indian population. Utilizing such approaches as the Talking Circle and Storytelling provides an excellent ways to educating and advocating groups in health prevention and promotion, obtaining information on the cultural constructs of illness, to better understand the barriers faced, fears, and or the problems associated with current illnesses experiences by the American Indian population. These approaches have been used in substance abuse programs, cancer control and prevention intervention, diabetes, obesity and wellness session. Incorporating traditional ways of communicating and respect, incorporates inclusion of all perspectives, equality of member status, and unrestricted timeframes that positively influences attendance of the community, encourages dialogue, and can impact positive behaviors regarding high-risk behaviors and prevention practices, such as immunizations, screenings, and treatment compliance. Several projects have successfully utilized Talking circles in cancer control,41 wellness,42 and diabetes intervention.43 Similar to the Hawaiian kokua44 groups (the concept of kokua is defined as a mutual willingness to assist without an expectation or return and without having to be asked), the Talking Circles model employs the concept of group support, a comfortable and safe environment, and the use of traditional American Indian ways of respect, resources, knowledge and insight41.

The Talking Circle and Storytelling approaches are not often seen in westernized group support sessions that are tightly regimented to one to two hour gatherings controlled by restrictive topical agendas. Talking Circles can be used in a group session to enable participants to gather and to explore issues, explain behavior, and to learn of means and methods to change behavior (such as smoking cessation). This group process of information generating and validating is an inexpensive method – that is both culturally sensitive and appropriate – that utilizes the social capital of the community to obtain much valued information on the health and welfare of the community.

The use of storytelling as a culturally appropriate approach to education has been used successfully45,42 in several intervention projects.42,46 American Indian cultural has traditionally been passed on through the use of oral narrative. It is a spoken culture, with a rich oral tradition. Language gives meaning and life to traditions through the telling of stories that pass from generation to generation. These stories, sometimes called legends or myths, have been told for thousands of years, and are still being told and retold, reshaped and refitted to meet their audience’s changing needs, or even created anew to fit contemporary situations and visions.

Traditional stories can reinforce the positive strengths of women, the special place of elders within the community, and the emphasis that women are the carriers of the culture and the givers of life. This reinforcement helped to encourage study participants to take care of their own health (by undergoing annual pap smears in addition to other illness preventative measures) and thus to be an important member of their community.

The traditional stories told during the course of a social event or as a part of a project transcend tribal boundaries, as they emphasize values significant to all Indian tribes. These stories nurture the culture and provide positive incentives for health promotion and prevention. Such a cultural approach to wellness is readily applicable to all tribes since the use of storytelling to relay important messages and to provide positive direction is a common tribal tradition. Employing traditional stories provides a culturally sensitive base for the presentation of educational curriculum and has been useful in behavior change interventions (diet and nutrition, physical activity, weight loss) in projects to increase knowledge (diabetes, cancer, tobacco control) and in general health care intervention models.

Another qualitative method, the focus group, has also been found to be of value in capturing normative perspectives on health and wellness among American Indian populations. When a focus group is initiated, the pattern of communication, the talking circle usually occurs; the result is a series of individual accounts instead of a normative interaction. Through the use of focus groups the stories of the youth and elders suggest the importance of addressing historical trauma, as noted in the introduction to health in this discussion, as well as the environmental context in which behaviors occur. Emphasizing the strengthening the family, addressing the environment in the schools and surrounding community, including the police, along with strengthening youth coping skills using traditional approaches are all important steps in parenting training, mental health intervention, and suicide prevention47.

Building culturally appropriate theoretical models, fostering the engagement of the community, the design of culturally appropriate interventions by employing CBPR approaches, Talking Circles and Storytelling methods can foster wellness among American Indian. While the history of colonialization, disease and trauma has been devastating for American Indian populations and we have a long way to go, tribes are taking greater responsibility for health and wellness, recovering ceremonies, expecting power sharing partnerships, and gaining economic and political strength.

Summary

Today, American Indians live in the shadow influenced by a history of oppression, repression, and intergenerational trauma experienced since Europeans first colonized North America.48,49. At the beginning of colonization, there was little room for the indigenous population in the plans of European newcomers. Military campaigns were responsible for destruction of tribal structures and indigenous population losses through warfare. However, it was the lack of immunity to the diseases that accompanied European colonizers and their rapid and sometimes deliberate introduction into American Indian communities that proved most devastating in the initial years. Since those early years, American Indians have been troubled by behavioral-related health conditions that threaten the health of the tribal nations and their members. High risk behaviors, such as substance abuse (cigarette smoking, alcohol and drugs), poor nutrition and obesity, violence and risky practices associated with unprotected sex, unsafe transportation and poor living conditions are compounded by serious lifestyles and environmental contamination. Together, these lead to a dim outlook for the health and wellbeing of future generations of American Indians.

More recent federal “self-determination” policies enacted in the 1970s created opportunities for tribes to assume the delivery of healthcare services to their members. The American Indian experience with regard to behavioral risk factors is both alarming and disgraceful. The health status of American Indians is below that of the general US population and has been for many years. Serious behavioral and social problems, leading to injuries and early death, are well documented in the American Indian population. Suicide rates are rising, and deaths due to homicide, accidents, and injuries continue as one of the leading causes of Indian mortality. High-risk behaviors such as smoking, poor nutrition, risky sexual practices, and sedentary lifestyles contribute to serious health conditions such as cancer, diabetes, nutritional diseases, and cardiovascular diseases.

It is recognized that many of the health related concerns for American Indians require academic research partnerships. Qualitative research approaches that foster greater understanding of cultural values, patterns of communication, and that build theoretical models to guide interventions hold promise. The health needs of American Indians are at critical stage. Resources are needed, both in terms of trained manpower and funding to address preventive, secondary and tertiary health care services. Health educators, especially those trained in chronic and behavioral health conditions are needed to assist individuals and groups in maintaining a healthy weight. It is important to do more than identify individuals and population groups who are at risk of obesity; proper support and sustainable interventions that are tailored specifically to American Indians’ needs, diets, and lifestyles need to be planned and offered for individuals with type 2 diabetes as well as those at-risk. Cultural connectivity (speaking tribal language, participating in American Indian practices, and feeling connected to community) is found to be associated with perceptions of wellness.50,51 Culturally-appropriate education and interventions need to emphasize community and cultural connectivity for improving wellness status. While progress has been made, and there is a growing spirit of cultural resurgence, much is yet needed.

The future status of health and wellness among American Indigenous populations requires an understanding of the inherited damage resulting from various federal policies along with attention to the strengthening of tribal wellness practices. Culturally appropriate interventions and wellness strategies are needed to respond to the poor health conditions observed. Identifying barriers and threats to wellness will serve as a guide for living a balanced life in harmony with one’s environment.

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34. http://minority health.hhs.gov/templates/browse.aspx?IvI=2&IvIID=52

35. Riding In, J. (1996). Repatriation: A Pawnee’s perspective. American Indian Quarterly, 20(2), 238-250.

36. Maldonado, R. (n.d.). Navajo Nation IRB/Research Protocols. The Native Peoples Technical Assistance Office. Historic Preservation Department, Cultural Resource Compliance Section, Window Rock, Arizona.

37. Kinzie, J. & Manson, S. (1987). Self-rating scales in cross-cultural psychiatry. Hospital and Community Psychiatry, 38, 190-196.

38. Manson, S., Shore, J., & Bloom, J. (1985). The depressive experience in American Indian communities: A challenge for psychiatric theory and diagnosis. In A. Kleinman & B. Good (Eds.), Culture and Depression (pp. 331-368). Berkeley, California: University of California Press.

39. Trimble, J.E., Scharron-del Rio, M.R. and Bernal G. (2010). The itinerant researcher: Ethical and methodological Issues in conducting cross-cultural mental health research. In: Dana Crowley Jack and Alisha Ali (Eds.), Silencing the self across cultures. Depression and gender in the social world. Oxford University Press.

40. Strickland, C.J., Chrisman, N.J., Yallup, M., Powell, K. & Squeoch, M. (1996). Walking the journey of womanhood: Yakama Indian women and papanicolaou (Pap) test screening. Public Health Nursing.13 ( 2): 141-150.

41. Hodge F, Stubbs H.1999. Talking circles: Increasing cancer knowledge among American Indian women. Cancer Research and Therapy. 8:103–111.

42. Hodge FS, Pasqua A, Marquez CA, Geishirt CB. (2002). Utilizing traditional storytelling to promote wellness in American Indian communities. J Transcult Nurs 13(1):6–11.

43. Struthers, R., Hodge, F.S., De Cora, L., Geishirt, C.B. (2003). The experience of Native peer facilitators in the campaign against Type 2 diabetes. J Rural Health 19(2):174–180.

44. Gotay, C.C., Banner, R.O., Matsunaga, D.S., Hedlund, N., Enos, R., Issell, B.F., & DeCambra, H. (2000). Impact of a culturally appropriate intervention on breast and cervical screening among native Hawaiian women. Prev Med.31 (5):529-37.

45. Tooze, R. (1959). Storytelling. Englewood Cliffs, NJ, Prentice Hall.

46. Strickland, C.J., Hodge, F., and Tom-Orme, L. (2009). Formative Evaluation and Community Empowerment among American Indian/Alaska Natives, In: Povin, Louise and McQueen, David V. Health promotion evaluation practices in the Americas.

47. Strickland, C. June. (1999). The importance of qualitative research in addressing cultural relevance: Experiences from research with Pacific Northwest Indian tribes. Health Care for Women International. 20(6), 517-525.

48. Brave Heart, M.Y.H. & DeBruyn, L. (1998). The American Indian holocaust: healing historical unresolved grief. American Indian and Alaska Native Mental Health Research: The Journal of the National Center, 8(2), 60-82.

49. O’Nell, T.O. (1994). Telling about Whites, Talkng about Indians: Oppression, Resistance, and Contemporary American Indian Identity. Cultural Anthropology. 9:1, pg 94-126.

50. Hill, D.L. (2006). Sense of Belonging as Connectedness, American Indian Worldview, and Mental Health, Archives of Psychiatric Nursing, Vol. 20, No. 5, pp. 210–216.

51. Hodge, F. & Nandy, K. (2011). Predictors of wellness and American Indians. Journal of Healthcare for the Poor and Underserved, 22(3), 791-803. PMC3287368.

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