This literature review cast a large net to identify and assemble the different veins of research that impact, primarily, Indigenous health promotion and interventions and, secondarily, immigrant health and interventions. It is especially concerned with specimens of participatory research, community-based participatory research (CBPR), and community generated media. Much of the data available is qualitative and/or quasi-experimental at best. There are a number of operational constraints contributing to this; and the research process in these populations is stymied by some of the same factors that are foundational to many of the salient health issues that emerge. Sociocultural isolation and invisibility to mainstream society coupled with a seasoned distrust of outsiders, government officials and academic researchers, along with a general state of marginalization and political disenfranchisement, all compound to establish similar barriers to positive health outcomes, quality research designs and impact evaluation.
This paper will explore a non-indexed list of salient themes that emerged in the intersecting categories of Indigenous health; community health and participatory research; community and Indigenous media; themes from the limited amount of quantitative data available; and the development of culturally specific instruments or programs.
The original criteria was intended to cast a more precise net on issues related to Indigenous community generated media, and even more specifically, community radio, in terms of its value as a health promotion venue. Though there is a significant amount of gray literature available on this topic – the United Nations Education, Scientific, and Cultural Organization (UNESCO) actually aggregates a wide selection on their website – the literature as a whole was lacking in terms of scientifically organized data that would support the scientific criteria for this review.
The wealth of less scientific literature is still immensely valuable, pragmatic and practice-oriented, if somewhat anecdotal. It has no doubt informed the more scientific dimensions of study. Still, this review aimed at collecting the more scientific exercises in data collection and presentation. Hence, in terms of the criteria for the review canon, the net was continually re-created and re-cast to follow and identify tangential veins of information that affect the health promotion potential of Indigenous community media at a foundational level. A total sample of 42 articles (n=42) was selected on merits of scientific credibility, collection and presentation of original data sets, and particular relevance to the review criteria; 36 are directly referenced in the text of this article.
It is generally accepted that the state of Indigenous health is one of neglect, compared with dominant surrounding settler populations. Again, this is due in a large part to individual- and institutional-level barriers that both contribute to negative health outcomes and stymie them from being properly addressed by well-intentioned outside health or civic organizations. Despite longtime commitments from surrounding government bodies, there has been a severe lack of economic evaluations conducted on Indigenous health care programs, making it that much harder for policy-makers to properly allocate funds and coordinate outreach (Angell, Muhunthan, Irving, Eades, & Jan, 2014). The opportunities for evidence-based planning remain slim. This begs to be addressed through more research focusing on outcome evaluations, impact measures, and other assessments that can advise program planning.
The mostly qualitative data and analyses available lend strong support to trends in CBPR. This is not just an exercise in morality, but a strategy for achieving: peak program or outcome sustainability, construct validity in research design, incentives for community stakeholder buy-in, and a host of other demonstrated and projected benefits. A well-documented focus group initiative has demonstrated that what works in mainstream communities may not function in the same way in Indigenous communities, even when it comes to widely standardized ideas about behavior and organization (Moore, 1971).
Suicide prevention measures are direly needed to respond to epidemics stemming from behavioral contagions within Indigenous communities that are linked to disruptions in cultural continuity and cultural identity (Chandler & Lalonde, 1998; Hanssens, 2008; Kirmayer, Simpson, & Cargo, 2003). The mental health status of Indigenous youth has also been correlated with the physical health status of their parents (Miller, 1996). Therefore, the epidemics of diabetes and other lifestyle related diseases – such as alcoholism – are entangled with the mental health and suicide epidemic of Indigenous youth. Indigenous peoples have the highest suicide rates of any other cultural or ethnic group in the world, and the risk is by far the highest for Indigenous youth (Leenaars, 2006).
In terms of interventions to reduce the risk that an Indigenous youth will turn to suicide, at least one research team found that such rate reduction is better achieved through an increase in protective factors, rather than a decrease in risk factors (Borowsky, Resnick, Ireland, & Blum, 1999). Another researcher found that community protective factors positively impact the amount of protective behaviors performed by adults (Allen et al., 2009). Protective factors in general seem to operate largely at the level of community in Indigenous societies, rather than at the level of the individual. This supports what seems to be a general idea that family and community play a more intimate role in establishing individual health within Indigenous society than other macrosocial variables might impact individual health in settler societies.
Causal links are difficult to establish quantitatively, but there is valid evidence that a history of cultural marginalization and oppression (often broadly conceived as ‘cultural genocide’) directly contributes to the current high levels of mental health issues present in Indigenous populations (Kirmayer et al., 2003). One ethnographic researcher concluded that, in terms of mental health disparities, the number one problem is loss of identity (Gone, 2007). All of these findings aggregate into an urgent call for culturally sound and community-based interventions and methodologically sound evaluations that also include culturally tailored strategies and community participation (Clifford, Doran, & Tsey, 2013). Contrary to the popular belief that mainstream health institutions are egalitarian in focus and impact, research has shown that indeed “race matters”, as do other SES indicators such as class, and cultural history (Tang & Browne, 2008). Evidence has demonstrated that promoting a strong ethno-cultural identity, high levels of community cohesion, and autonomous political development can all contribute to the improvement of mental health outcomes for Indigenous populations (Kirmayer et al., 2003).
The demonstrated importance of community level health factors underscores the call for more CBPR conducted in collaboration with Indigenous communities. This means involving members of each targeted community at each level of research and planning, from conception, to implementation, to evaluation. Essential to this process is a preemptive understanding of the contexts of colonialism on the part of the research team, which includes allowing proper time in the planning and pre-planning stages to establish high levels of trust among the community (Voyle & Simmons, 1999). This should include attempts to support and accommodate native language use in recruitment, intervention, and dissemination of results, otherwise there could be an inherent discrimination at work (Farquhar et al., 2008). Communication and language barriers, as well as ineffective translation services, have been identified as perceived barriers to satisfying health needs in immigrant communities (Cristancho, Garces, Peters, & Mueller, 2008) and could be even more problematic for speakers of some of the more endangered Indigenous languages. Beyond the importance to outreach efforts, supporting Indigenous language retention is an important health service in and of itself.Language retention holds its own among other cultural constructs in terms of measured correlation with reduced suicide rates among Native youth (Hallett, Chandler, & Lalonde, 2007).
The training and employment of Indigenous community health workers (ICHWs) has proven to be an invaluable resource in terms of integrating cultural values into health provision, health promotion efforts targeting Indigenous youth, and promoting the sustainability of initiatives by building them on a foundation of Indigenous autonomy and recognition in health service delivery and research (Hurst & Nader, 2006). The use of community health workers has been demonstrated and documented to have a positive correlation with decreasing perinatal mortality and improving pregnancy outcomes (O’Rourke, Howard-Grabman, & Seoane, 1998) in rural Indigenous regions, as well as in significantly reducing neonatal mortality rates in similar settings (Manandhar et al., 2004).
Mental health promotion that emphasizes community empowerment has been associated with positive health outcomes in Canadian First Nations communities (Kirmayer et al., 2003). Communication has been identified as a predominant issue underpinning such results.. The importance of, and intersection between, community and communication have been demonstrated to impact compliance and cooperation in vital mental health interventions (Eley et al., 2006); and as well, towards accessing the “intrinsic strengths of indigenous worldviews and practices” in regards to basic research aimed at creating “positive transformations in community health” (Wolsko, Lardon, Mohatt, & Orr, 2007). And with communication factors within the community strongly emerging as a defining issue, the discussion will now move towards the related constructs of Indigenous and community-generated media.
Indigenous media has been widely recognized as an essential and central service to the organization of Indigenous community life. It helps increase social cohesion and serves as an educational venue in the community, particularly in the lives of youth (Meadows, 2009). Social capital, or community buy-in, is a significant predictor of sustainability in such endeavors, and the social capital of an Indigenous community radio station is also related to the age composition of its listener base. The participation of volunteer networks in the community is also an important factor for community media in achieving optimal social capital (Van Vuuren, 2002). It’s interesting to note the symbiotic relationship between Indigenous media and community health. In fact, Indigenous community media could also be conceived of as a community based, participatory intervention. A longitudinal set of studies on Indigenous community radio in Bali found that when community radio stations adopted a more health promotion and community development oriented approach – activity which supported off-air activities within the community – community perceptions of the station tended to evolve positively(Waters, James, & Darby, 2011). This would naturally lead to an increase in vital social capital.
One very outstanding case in point: Indigenous community radio, and community radio in general, play an increasing role in the sociopolitical landscape of Nepal. A UNESCO report found that there is great potential in expanding this community media sector towards achieving both long term and short term impacts in socio-economic development and improvements in education and health (Pringle & Subba, 2007). Another research team in Nepal concluded that Indigenous communities can reclaim, reinforce and sustain their cultural identity through active participation in community generated media. It not only reinforces an official recognition of Indigenous identity amongst the larger sociopolitical landscape, but provides a venue for other routes to empowerment as well (Dahal & Aram, 2013). Beyond the politics of culture and identity, a research team in Australia confirmed that Indigenous community radio plays a significant role in times of crisis and natural disasters – as it notably did in Nepal after the earthquake in April of 2015. The roles Indigenous community radio outlets play can range from organizational, to inspirational (on-air counseling), to community advocacy (challenging falsities in mainstream media narratives), all while providing the larger service of strengthening social cohesion (Meadows, Forde, Ewart, & Foxwell, 2005).
One CBPR intervention that supports community radio’s status as a useful health promotion tool was able to achieve positive outcomes in a health promotion campaign aimed at impacting nutritional outcomes in Indigenous youth, a primordial prevention measure towards outcomes of diabetes (Matta, 2011). Studies like these are encouraging because radio sets are no longer considered a luxury and are attainable in even the most remote communities on Earth. Positive trends in community radio delivery and access have only increased their popularity as a device for media consumption (Banjade, 2007). Because of this increasingly affirmed relevance in modernity, it is vital that educational curriculums and information disseminated through community radio be as up to date and scientific as possible, especially in areas related to natural disasters and weather changes (particularly important to subsistence economies and coastal communities) related to climate change (Piya, Maharjan, & Joshi, 2012).
A small sample of randomized controlled trials (RCTs) was identified in the scope of this literature survey. Two of these, of particular relevance to the themes presented in this paper, are also referenced in a separate section due to the weight such trials hold in the scientific community. A 2007 RCT that tested a parental intervention program aimed at Indigenous Australians confirmed, with empirical support, the effectiveness and overall fit of a culturally tailored approach (Turner, Richards, & Sanders, 2007). When a participatory intervention involving community women’s groups in Nepal was tested, the birth outcomes in the rural target population improved greatly at a low fiscal investment (Manandhar et al., 2004).
The important concept of ‘cultural continuity’ is supported by sound quantitative evidence in regards to its negative correlation with Indigenous youth suicide rates in First Nation Canadian communities. Researchers found that higher levels of Native language proficiency rates at the community level – a strong construct of cultural continuity – outperform other cultural measures that have been previously evaluated. In fact, youth suicide rates effectively drop to zero (and dip lower than the national average for non-Indigenous youth) in communities marked by the highest Native language proficiency rates (communities where more than half of the population reports conversational fluency). On the other hand, in bands where less than half of the members are conversationally fluent, suicide rates spiked upwards toward six times the national average (Hallett et al., 2007). Related qualitative data supports this as well, as markers of assimilation tend to reflect or predict more negative health outcomes. Higher levels of acculturation (assimilation to the dominant culture) tend to result in increased levels of stress and negative health outcomes (Wolsko et al., 2007). This is mirrored in research measuring acculturation and eating habits in the context of the diabetes epidemic in Latino immigrants in the U.S. as well (Pérez-Escamilla & Putnik, 2007). Likely driven by such findings, the Center for Disease Control (CDC) conducted a community based participatory intervention with Native communities in the U.S. called, ‘Traditional Foods’, in the scope of their diabetes program. It was based on the idea that food sovereignty and acculturation issues could actually impact diabetes rates. This program is fairly recent and the results are still being written up but CDC Health Educator, Dr. Dawn Satterfield RN, PhD, has expressed extremely positive sentiments about the impact and outcomes of the endeavor.
A fair amount of research has also been conducted in regards to the development of culturally specific instruments or programs. One such instrument, referred to as IRIS (Indigenous Risk Impact Screening) was evaluated according to psychometric validity and found to be statistically valid as a screening tool for alcohol, drug, and mental health issues in Aboriginal and Torres Strait Islander peoples (Schlesinger et al., 2007). Another researcher found that specialized (culturally tailored) training for mental health professionals (Indigenous and non-Indigenous) proved valuable in the delivery of mental health assessments and care plan packages designed for Aboriginal clients (Nagel, Thompson, Spencer, Judd, & Williams, 2009). In terms of reducing health disparities worldwide, which are often at their highest where Indigenous groups are concerned, another researcher concluded that the international community should focus on the internet as a medium to deliver free, evidence-based interventions to marginalized populations. The context and directness of such delivery could also support an increasing degree of autonomy in the target populations, and they might be able to access it as an alternative to more mainstream programs that present culturally significant barriers (Muñoz, 2010). Such programs could conceivably be cheaper to develop and implement, and more resources could be put into culturally tailoring interventions and programs for each unique audience. Supporting the culturally tailored approach, another researcher found that mental health symptoms and related constructs in Indigenous groups can also vary in unexpected ways. One such instrument that was developed and tested towards assessing this is called ‘Strong Souls’. Strong Souls demonstrated reliability, cultural appropriateness, and validity as a tool for screening Indigenous youth for social and emotional well-being issues somewhat unique to their populations (Muñoz, 2010). Photovoice, another participatory media-centric method, has demonstrated potential in CBPR efforts by enabling Indigenous groups to communicate in a way that bridges disparities in power (Castleden & Garvin, 2008).
In order to truly maximize on the potential of CBPR methods, Indigenous communities must be guaranteed an equal share, if not full ownership, of the research process from conception to evaluation. This is counterintuitive to many strains of paternalism that have seeped into academia and other public sectors, where good intentions have often been unknowingly swimming in the waters and context-specific outcomes of colonialism. The good news is that investigators are finding ways to heal these barriers. Aggregated research conclusions, as detailed here, suggest the importance of not just respecting the specific cultural uniqueness of Indigenous communities, but of lending efforts toward co-creating a healthy atmosphere for cultural continuity and cultural sovereignty.
The symbiotic relationship that community generated Indigenous media is capable of sustaining with targeted communities – with reciprocal positive impacts on community and individual level health outcomes, and sustainability for the media outlet – should definitely be a point of focus. Indigenous community radio has shown capabilities for impacting population and individual health through health promotion campaigns; disaster relief efforts; providing a public venue to express cultural identity and achieve cultural continuity (both demonstrated predictors of positive health outcomes); and has been associated with broader trends of community and individual empowerment and socio-economic development. Community radio stations that focus on health promotion and community empowerment have been rewarded with a stronger base of support in the community, This suggests Indigenous community radio and Indigenous community health promotion sectors can effectively collaborate in creating a win-win context of mutual support and benefit. Again, this contributes to the sustainability of health promotion campaigns, which can then operate from a nexus of community empowerment and subsequent impact, and to the community media venues themselves.
The Fourth World Journal (FWJ) is the world’s leading publication for ideas and analysis about and by writers from some of the world’s more than six thousand Fourth World nations. FWJ is published periodically by DayKeeper Press as a journal of the Center for World Indigenous Studies.
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