1. Resilience and Indigeneity: A life course approach for American Indian, Alaska Native and Native Hawaiian health
Presenters: Christina Oré, MPH and Nicolette Teufel - Shone, PhD
2014 International Indigenous Development Research Conference, Auckland, Aotearoa/New Zealand

2. Exploring Resilience Welcome and Introduction
Purpose: to explore resilience along the life course
Objective: to present a series of literature reviews and original research
Rationale: persistent health inequality and inequities require a shift in mind set and practice
Audience: tribal community members, leaders, health practitioners, health researchers and policy makers
Origins: Who are we? What is our approach and method?
Process of discussing the state of public health practice and addressing health disparities within American Indian and Alaska Native Tribes and communities
Proposed looking at the life stages starting with Elders as impacted by life course and source of resilience and regeneration…..and respect…..
Conceptual Framework: Life course approach ----spiral of life ----

3. American Indian (AI), Alaska Native (AN), Native Hawaiian (NH)

4. Origins* Introduction Graduate Students
Center for American Indian Resilience (CAIR)
Special Topics course
Graduate Students
MPH and DrPH programs at the University of Arizona
Shared interest and lived experience with resilience, impact of life course on health and wellbeing, and desire to improve public health practice
Approach and Methods
Met weekly, January – May 2014
Shared decision making process
Series of life stage literature reviews
Life course as
Life stages for structure
Core themes and concepts of life course as theory and methodology
The purpose of the series was to understand the past, present, and promise in AIANNH health research along the life course: Elders, Adults, Adolescents and Children. The specific aims were 1) describe current research practice, 2) synthesize findings, and 3) provide implications for future public health research. The purpose of this literature review was to define the life course theoretical approach, its current application, and implications for AIANNH public health research, specifically for resilience research
And lived experience
Intuitively understanding potential contribution of life course approach
Series approach is an iterative process
Topic remains the same
Thesis statements changed

5. Series of literature reviews
Life course framework
Christina Oré and Nicolette Teufel-Shone
Adolescents
Elders
Aurora Trujillo
Agnes Attakai
Sheena Brown
Carmella Kahn- Thornbrugh
Self determination and Sovereignty
Adults
Adeline June-Tsosie
Priscillla Sanderson and Octavianna Trujillo
Michele Henson
Athena Crozier and Tara Chico
Stephanie Rainie
Literature review – Life Stages
Elders, Adults, Adolescence, and Early Childhood
Standard Systematic Review guidelines ( modified PRISMA)
Series approach is an iterative process
Topic remains the same
Thesis statements changed
Life course as
Life stages for structure
Core themes and concepts of life course as theory and methodology

6. Historic Framework Tribes Full Sovereignty (pre 1778)
Policy of Conquest
Assimilation and Reorganizing us
(1779 – 1934)
Trying to eliminate us (1935 – 1975)
American Indian, Alaskan Natives and Native Hawaiians (AIANNH) health disparities are rooted in a history of US colonization, assimilation policies, marginalization and discrimination.
These policies affected AIANNH along lifespans and across generations, both individually and collectively; it is a central theme in the life course approach.
Yet, the majority of AIANNH disparities research is focused on proximal causal pathways, disease specific correlations, individual behavior change and non-Indigenous concepts of health and wellbeing.
Federal Self determination Self Governance
( )
Indigeneity
(Re )claiming (Re)generation (Re) naissance
(2010 -
Shelton, 2004

7. State of the Practice American Indian and Alaska Native Public Health
Deficit approach model
Assumptions of adaptability evidence based research
Programs and services oriented towards individual behavioral change
Non indigenous concepts of health and wellbeing
Current practice is limiting and potentially harmful
Overshadows and start to stifle growth, innovation, creativity being done within tribal communities to achieve health equity
Perpetuates stigmatization and trauma
Decades of disparities research yet there is no appropriate, evidence based intervention specifically responding to the needs of AIANNH women.
Commonly held notion that the interventions can be adapted
Health disparities or inequities: Metric and Generic difference in health and wellbeing status
Social justice:
avoidable, unfair, and unjust (Whitehead, 1992 in Braveman, 2006) and discrimination, disadvantage, marginalization (Braveman, 2006)
eliminate disparities to achieve health equity: Responsibility and Obligation
Important clarification for measurement, accountability and allocation of resources at federal, state and tribal level

8. Literature Review: Life course framework
Purpose statement of literature review
To define life course theoretical approach, its current application, and implications for AIANNH public health research, specifically for resilience research
Methods
Standard systematic review guidelines and 3 databases ( Pubmed, JSTOR, and ERIC)
Inclusion Criteria
1) peer- reviewed, available, English language articles;
2) published between January 1, 1970 – September 30, 2014;
3) identify life course/ life span/ life stage;
4) Identify American Indian (AI), Alaskan Native (AN), and Native Hawaiian (NH);
5) identify socio-economic, socio-cultural, political determinants;
6) recognize historical or temporal determinants
Analysis
Descriptive and content analysis reference life course core concepts
Intro
Why am I doing the paper?
Where are the gaps in the field that are causing the problem or could be filled with postive imapct? What aspect of ph am I addressing?
Background: life course for etiology of disparities rooted in colonization marginalization etc
Yet current public health practice individual focused etc
Using a life course and asset-based framework, a series of eight (8) literature reviews were conducted from January – September 2014.

9. Life Course: theory and methodological tool
Life course approach is a way of considering health development over a lifetime and across generations
Timeline, Timing, Environment, and Equity
Connection
Timing: Individual and collective historical events
Environment: Physical, economic, social factors across the life course
Equity:
Understanding how disparities created, exacerbated or mitigated, and potentially transmitted
Conditions shape vulnerability or resilience to health effects of adverse exposure
Directs our gaze upstream to fundamental causes now and earlier in life
Interactive process and lifelong development so life long moments to support health wellbeing
Understanding health disparities: How it is created? Exacerbated? Mitigated? Transited?
Intergenerational transmission
Defining terms: Plasticity (in utero stressors) and Epigenetics (external stressors)
Like many concepts in public health the life course approach is hard to pin down. It’s a theoretical approach with origins in sociology later picked up and used by anthropologist, gerontologist and most recently maternal and child public health researchers. AIANNH researchers are using a more social science interpretation of the concept, based on the work of sociologist G. Elder. Public health researchers particularly maternal and child health and social epidemiologist have adapted the concept slightly to speak directly to health and inequities.

10. Results: substantive and relates to the thesis
Public health (incl epidemiological and medical) literature is limited to descriptions of AIANNH resilience and inequalities as individual processes
Social science (sociology, anthropology, social work) literature strong cultural components suggest these concepts are linked to Indigeneity and collectives processes of navigating and negotiating uncertain resources
Life course is being used as a framework to explore historical trauma and decolonization in AIANNH health and wellbeing
Analysis
A total of 320 articles were identified and 16 were selected for full review. Data was extracted into Endnotes (version X7.2) and imported into Microsoft Excel. Descriptive and thematic content analyses were conducted, using components of the life course approach.
Structured by life course stages
primarily used in AIANNH gerontology, maternal and child health and mental/behavioral health studies
Findings from the 16 articles support the assertion that the socio-political environment and issues of equity, both historic and contemporary, are significant drivers of AIANNH health disparities

11. Showcase: 5 articles
Walls & Whitbeck (2012) Intergenerational Effects of Relocation Policies on Indigenous Families
Intergenerational, original research, American Indian
McCloskey (1998) Three generations of Navajo women: negotiating life course strategies in the eastern Navajo agency
Browne, Mokuau and Braun (2009) Adversity and resiliency in the lives of Native Hawaiian elders
Elders (implications for intergenerational), theoretical, and Native Hawaiian
Jackson and Chapleski (2000) Not traditional, not assimilated: elderly American Indians and the notion of ‘cohort’
Elders (role), original research, American Indian
Walls and Whitbeck (2011) Distress among indigenous North Americans: Generalized and Culturally Relevant Stressors
Adults (caregivers), original research, American Indian
Findings from the 16 articles support the assertion that the socio-political environment and issues of equity, both historic and contemporary, are significant drivers of AIANNH health disparities
The life course perspective offers a way to view individual biographies over time through a series of life transition and trajectories that are situated and influence by historical forces, timing of event and human agency. The perspective emphasizes shared networks interdependent relationship and “linked lives” elucidating the way that historical events share lives across generations (Elder 1998; George, 1999).

12. Discussion
What can be drawn from reviewing the literature so far? Where might the discussion proceed?
Underutilized framework for understanding both pathways and contributors ( i.e. historical trauma, early childbearing, resilience) of health disparities and
For burgeoning study of resilience, social determinants, embodiment in health equity research ( paradigm shift)
he life-course approach is an underutilized framework for understanding both pathways and contributors (i.e. historical trauma, early childbearing, resilience) of health disparities and for achieving health equity.

13. Implications for Resilience*
Reframing discourse on American Indian health and health inequities - Teufel-Shone et al. (2014) (under review)
Resilience – a dynamic interaction between between risk and protective factors
Link between American Indian health and resilience is poorly understood.
AI communal and intergenerational resilience has not been researched
Resilience in
Elders ( Attakai and Kahn-Thornbrugh)
Adolescents ( Trujillo and Brown)
Adults ( Hensen and June-Tsosie)
Life stories ( Crozier and Chico)
In the context of exposure to significant adversity, resilience is both the capacity of individuals to navigate their way to the psychological, social, cultural and physical resources that sustain their wellbeing and their capacity individually and collectively to negotiate for these resources to be provided and experienced in culturally meaningful ways (Ungar, 2011, p 225)
Within burgeoning resilience in American Indian, Alaska Native and Native Hawaiian health research
Tribally defined resilience…..no models
Not solely an individual trait

14. New Directions - Indigeneity
Indigeneity – knowledge creation and sharing
“An enduring relationship between populations, their territories and the natural environment” ( Durie, 2005, p. 302)
Working in the Interface distinctiveness of knowledge systems
Working from within Indigenous peoples culture and worldviews
Elders interaction with Youth ( Attakai and Kahn-Thornbrugh)
Tribal government
Tribal control on health services and public health systems (i.e. 638, Affordable Care Act)
Community participatory research (Sanderson and Trujillo)
Data as sovereignty ( Rainie)
Space opened by your scholarship to embody and bring into our work

15. References
Braveman, P. (2006). Health disparities and health equity: concepts and measurement. Annu. Rev. Public Health, 27,
Braveman, P. (2013). What is Health Equity: And How Does a Life-Course Approach Take Us Further Toward It? Maternal and child health journal, 1-7.
Durie, M. (2005). Indigenous Knowledge Within a Global Knowledge System. Higher Education Policy, 18, 301 – 312.
Krieger, N. (2001). Theories for social epidemiology in the 21st century: an ecosocial perspective. International Journal of Epidemiology, 30,

16. References
Shelton, B.L. (2004). Legal and Historical Roots of Health Care For American Indians and Alaska Natives In the United States. Issue Brief. Henry J. Kaiser Family Foundation
Teufel- Shone, N., Sanderson, P., Ehiri, J., Reese H., & Tippens, J. (under review). Resilience and American Indian Health: A Systematic Review of a Promising Framework. American Journal of Public Health.
Ungar, M. (2011). The Social Ecology of Resilience: Addressing Contextual and Cultural Ambiguity of a Nascent Construct. American Journal of Orthopsychiatry, 81, (1), 1 – 17.
Walters, K., Mohammed, S.A., Evans-Campbell, T., Beltran, R.E., Chae, D.H., & Duran, B. (2011). Bodies Don’t Just Tell Stories, They Tell Histories: Embodiment of Historical Trauma among American Indians and Alaska Natives. Du Bois Review, 8 (1),

17. Thank You
This work was supported by the Center for American Indian Resilience (CAIR), a NIH-NIMHD P20 Exploratory Center for Excellence(1p20MD006872) awarded to Northern Arizona University with subcontracts to University of Arizona and Dine College.