American Indian and Alaska Native Early Childhood Health: A Systematic Review Nicolette Teufel - Shone, PhD College of Public Health, University of Arizona 2014 Native Research Network Conference, Phoenix, AZ

Conceptual framework  Using the Life Course Approach, this review examines the social and political determinants that shape AIAN early childhood health  For all populations, childhood development and health has both lifelong and intergenerational effects (Shonkoff et al. 2012)  Identifying contextual factors that impact resilience and stress early in life is essential to guide public health action for a healthier population

Objective of this review  Understand the state of the science which serves as the foundation for public health action to health equity  Identify how social determinants of health and the socio-ecological model are used in understanding and improving the health of young AIAN children  Understand context

Methods  Standard procedures of the Cochrane Collaboration (2008) for systematic review of primary research in health care and policy  Three databases searched: PubMed, Web of Science and EBSCO which includes PsycINFO and CINAHL  Search terms: American Indian (AI) Children, AI Early Childhood; Native American Children; Native American Early Childhood; Alaska Native (AN) Children; AN Early Childhood; AI Children and Families, Native American Children and Families; and AN Children and Families

Study Inclusion and Exclusion Criteria  Available in English; peer-reviewed  Available electronically. published by April 1, 2014  Target population was predominantly AI and/or AN children, < 12 yrs  Described a nonclinical encounter that addressed the context of health outcomes and/or an intervention designed for AI/AN children  Applied socio-ecological or social determinants of health framework  Limited to AI/AN children of US tribes who entered into treaty agreements and endured a unique set of stressors linked to the residential, educational and governance requirements of the US government (Gone & Trimble, 2012)  Native Hawaiians not included, not covered by Indian Health Service, an agency having a distinct, homogenizing impact on the services provided to young AI/AN children

Number of different articles identified in database search (n=287) Titles and abstracts excluded, focus not early childhood (n=195) Articles reviewed by primary categories (n=77) Excluded, socio- ecological framework not applied ( n= 70) Articles included (n=7), all address family dynamics and influence Over-nutrition in AIAN early childhood (n=37) Dental health in AIAN early childhood (n=16) Family dynamics and influence (n=17) Community dynamics and influence (n=7) Excluded as Other ( n= 10) Nominal Categorical Analysis of Literature: American Indian and Alaska Native Early Childhood

Results  Of the initially identified 287 articles addressing AI/AN early childhood health, only 7 met the criteria that included use of socio-ecological framework, addressing context  All 7 addressed family dynamics or family oriented services influence on childhood health  Four addressed socio-cultural resources and stressors in AI families that influence childhood physical, mental and emotional health  Three 3 addressed family behaviors grounded in AI/AN values, worldviews and experiences that shape early childhood physical, mental and emotional wellness

Resources and stressors of AI families with young children  Cunningham-Sabo et al. (2008) Focus groups with 41 parents and staff of Navajo Head Start Program  Identified need for: 1) community-level action to change the food environment ; 2) stronger parenting skills to control the food environment; and 3) culturally relevant strategies for caregivers  Bauer et al. (2012) Survey of 432 parents or caregivers of Lakota children  Food insecurity associated with: 1) practice of feeding children calorically dense foods linked to history of food scarcity and desire to have heavier children; and 2) pervasive feeling of inadequacies, stress and depression

Resources and stressors of AI families with young children  Crofoot and Harris (2012) Review of historical practices that devastated AI families and policies of Indian Child Welfare Act  Child welfare systems retain elements of systematic bias from 200 years of US policy challenging AI families.  Need systems based on AI strengths, e.g., interdependence of extended family, respect, and role of elders in leadership, discipline and spiritual guidance  Bussey and Lucero (2013) Case study of Denver Indian Family Resource Center (DIFRC) and AI families in the Denver area  DIFRC implemented a Family Preservation Model that addresses family stressors and mental health, cultural strengths (extended family/kinship) and referral to materials resources.  System change and improvement in staff training

Family Behaviors that shape the early childhood experience  Cheshire (2001) Interviews with 10 dyads, AI mothers + children  Cultural transmission - Children expected to be quiet, observe and learn  Listening is highly valued; asking questions is non-traditional transmission  Red Horse (1997) Literature review and counseling experience with AI families  In traditional families, children raised in extended kin systems ; household residents are multi-generational, related by blood, marriage or adoption  Family members are always reminded of their place and responsibilities in the kinship system  Simmons et al. (2004) SAMSHA funded (Circle of Care) AIAN communities work to redefine serious emotionally disturbed (SED) children  Definitions assert the role of the social and cultural environment in shaping children’s physical, emotional, spiritual, and intellectual health  SED Children with SED are from families who experienced trauma and suffer from historical wounding. Shame and anger are acted out in addiction, suicide attempts, violent acts and other ant-social behaviors

Discussion  Seven articles quite different, commonality is focus on context  Literature on early AI childhood health has  Focused on epidemiology of health conditions, predominantly over-nutrition and dental health  Have applied a framework that guides assessments and interventions that emphasizes responsibility of parents  Reflections of the socio-political-historical context of family resources, stressors and behaviors influencing the physical, mental and emotional health of young AI children is not prevalent in the literature

Conclusions  Impact of social injustice on AIAN childhood health can not be change in period of most external funding sources  Identification of short-term indicators of change in social determinants of health is needed and acceptable as feasible outcomes  Future public health efforts to understand and enhance AI childhood health should  Examine contexts that yield healthy physical, mental and emotional outcomes; identify factors linked to positive health outcomes  Identify, discontinue and change social-political and historical systems that reinforce family trauma by blaming families;  Need to focus on AI values that supporting raising healthy children in balance with their social and physical environment

Questions?

Contact Information  Nicolette I. Teufel-Shone, PhD   Work supported by:  Center for American Indian Resilience ( CAIR)  NIH – NIMHD P20 Exploratory Center of Excellence (1P20MD006872)  Awarded to Northern Arizona University  Subcontracted to University of Arizona and Diné College