1. N Teufel-Shone, PhD, University of Arizona J Tippens, MA, MPH, University of Arizona H. Rees, MPH, University of Arizona J Ehiri, PhD, MSc University of Arizona P Sanderson, PhD, CRC, Northern Arizona University

2. Some say that Coyote wears a black leather jacket and high top tennis shoes That Coyote thinks that Rose is a good singer That Coyote eats frybread peanut butter and jelly That Coyote will use you if you don’t watch out That Coyote will teach you if you let him That Coyote is very young the new one That Coyote is a survivor Some say Coyote is a myth Some say Coyote is real  - Harry Fonseca

3.  Prominent role in Native American storytelling  Complex character that is at once ◦ old and young ◦ wise and vulnerable ◦ uncompromising and adaptable ◦ teacher and fool ◦ always a survivor  Stories are culturally shared lessons and memories of resilience

4.  Understand state of the science relative to Native American health ◦ Use of asset based approaches ◦ Use of resilience  Identify factors that increase or hinder resilience in the life course of Native Americans  Review past and current use of resilience ◦ Contributes to the dialogue identifying the value of the concept in public health ◦ Helps determine if the concept holds promise for guiding a frameworks for effective, culturally relevant public health efforts in Native American communities

5.  Resilience - a process that offsets social inequity resulting in health disparities  Almedon and Glandon (2007) and Ungar (2012) discuss resilience as a dynamic process between risk and protective factors  Resilience is more than surviving but engaging resources to thrive  Kirmayer et al. (2011) reminds us that resilience changes across the lifespan

6.  US Public Health is torn between a focus on social determinants of health and personal responsibility  Globally, the focus is social determinants of health as demonstrated by WHO and Marmot et al.’s (2013) Closing the Gap in One Generation  How do studies of resilience fit in this dialogue?  Is resilience a personal trait?  Is collective or community resilience a social determinant of health?

7.  Defined as linking a network of adaptive capacities after adversity; collective engagement of resources to thrive in an environment characterized by change, uncertainly, unpredictability and surprise (Norris et al. 2008; Magis 2010)  Has work in Native American health considered the multiple ways in which identity, group membership and ideological commitment influence people’s health behaviors and mental health (Wexler et al. 2009)?

8.  Standard procedures of the Cochrane Collaboration (2008) for systematic review of primary research in health care and policy  Nine databases (1/1/1980 to 12/31/2013)  Search terms used ◦ Resilience ◦ Collective Resilience ◦ Community Resilience ◦ American Indian ◦ Native American ◦ Chronic Disease ◦ Chronic Illness

9.  English, peer reviewed  Target population - American Indian/Native American  Describe a non-clinical encounter  Operationalizes cultural, community or collective resilience  Limited to 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, reduced impact of IHS which has had a distinct, homogenizing impact on health services

10.  A total of 724 potential articles were identified  54 abstracts met the inclusion criteria  9 included a discussion of resilience promoting strategies and resources within Natibe populations  Nominal group analysis by age ◦ 4 resilience in adolescence ◦ 2 resilience in college age students ◦ 2 resilience among elders ◦ 1 intergenerational

11.  Outcome measures – educational achievement  Individual protective factors ◦ Enculturation ◦ Maternal warmth, relationship ◦ Community support ◦ Social support from friends ◦ Self-esteem ◦ Cultural identity (3 of 4)  Individual risk factors ◦ Perceived discrimination

12.  Individual Protective Factors ◦ Family support (educational success) ◦ Problem solving skills (lower suicide risk) ◦ Strong cultural and tribal identity and engagement (educational success and lower suicide risk)

13.  Contributing to resilience ◦ Cultural connection, ability to live bi-culturally ◦ Family and tribal community connectedness ◦ Spiritual belief, connectedness with the Creator ◦ Belief that resilience was passed down by the Ancient Ones and to be honored ◦ Strong sense of identity and pride ◦ Self-confidence and self-esteem ◦ Educational attainment and employment ◦ Being responsible and accountable ◦ Strength comes from the unity of communities not individuals

14.  To enhance resilience, need to discuss shared trauma, both historical trauma and contemporary personal and social injustices  Emphasize traditional healing practices  Discussion coping strategies  Promote collective healing  Again focus is on collective, rather than individual resilience

15.  Protective factors ◦ Family and community support – primary ◦ Cultural connection – secondary  Risk factors ◦ Discrimination ◦ Inadequate coping skills  No research on mid-age adults, particularly parents who are influencing future generations  Academic achievement has been used as a indicator of resilience for youth, too narrow  Collective resilience not explored

16.  Resilience does not have a strong presence in public health research  Resilience has been discussed as a social determinant of health, but not explored (Kirmayer et al. 2011)  Need to understand collective and community resilience ◦ Relative to social and cultural capital ◦ Assess if collective resilience contributes to improved health outcomes

17.  Almedom, A. M., & Glandon, D. (2007). Resilience is not the absence of PTSD any more than health is the absence of disease. Journal of Loss and Trauma, 12(2), 127-143.  Gone, J., & Trimble, J. (2012) American Indian and Alaska Native Mental Health: Diverse Perspectives on Enduring Disparities. Annu. Rev. Clin. Psychol.; 8:131–60.  Kirmayer, L. J., Dandeneau, S., Marshall, E., Phillips, M. K., & Williamson, K. J. (2011). Rethinking resilience from indigenous perspectives. Canadian journal of psychiatry. Revue canadienne de psychiatrie, 56(2), 84.  Magis, K. (2010). Community Resilience: An Indicator of Social Sustainability. Society and Natural Resources;23(5):401-416.  Marmot, M. et al. (2008). Closing the Gap in a Generation: Health Equity through Action on the Aocial Determinants of Health. Final Report of the Commission on Social Determinants of Health.  Geneva, World Health Organization  Norris, F. H., Steven, S.P., Pfefferbaum, B., Wyche, K. K.. & Pfefferbaum R.L. (2008) Community Resilience as a Metaphor, Theory, Set of Capacities, and Strategy for Disaster Readiness. Am J Community Psychol 41:127–150  Ungar, M. (2012). Social ecologies and their contribution to resilience. In M. Ungar (Ed.), The Social ecology of resilience: A handbook of theory and practice (pp. 13-32). New York: Springer.  Wexler, L. M., DiFluvio, G., & Burke, T. K. (2009). Resilience and marginalized youth: Making a case for personal and collective meaning-making as part of resilience research in public health. Social Science & Medicine, 69(4), 565-570.

18.  Nicolette I. Teufel-Shone, PhD teufel@email.arizona.edu  Priscilla R. Sanderson, PhD, CRC priscilla.sanderson@nau.edu  Mark C. Bauer, PhD mcbauer@dinecollege.edu CAIR is supported by a NIH-NIMHD P20 Exploratory Center of Excellence award (1P20MD006872) to Northern Arizona University