Developing Indigenous-Centered Healing, Health, and Wellness Frameworks to Strengthen Indigenous Health Systems, Decolonize Public Health, and Achieve Health Equity

Abstract

Over the past 20 years, national and global health initiatives have increasingly used resources, implemented tools, and proposed policies to change the social determinants of health contributing to health inequities. The World Health Organization and the US Centers for Disease Prevention and Control have applied their evidence-based frameworks to these efforts.

Yet, for tribal nations and Indigenous communities in the United States, these frameworks’ relevance and applicability are limited. The disproportionate impact of the COVID-19 pandemic (e.g., incidence and mortality rates) highlighted Indigenous epistemologies and realities (e.g., tribal sovereignty, strained state–tribal health systems) that were either missing or did not conceptually fit in these social determinants of health frameworks.

We describe findings from the 2018 to 2024 Indigenous Social Determinants of Health Project completed by Seven Directions, an Indigenous public health institute. We propose constructs for Indigenous healing, health, and wellness frameworks developed by and for tribal nations and Indigenous communities. Practitioners and policymakers may use these tailored frameworks in collaboration across sectors (e.g., public health, social services, behavioral health) to align systems for transformational change, decolonize public health, and achieve health equity. (Am J Public Health. 2025;115(5):726–731. https://doi.org/10.2105/AJPH.2024.307958)

“As long as you remember what you have seen, then nothing is gone.

As long as you remember, it is part of this story we have together.”

—Leslie Marmon Silko, Ceremony, 1978

Tribal nations and Indigenous communities (i.e., American Indian and Alaska Native [AIAN] peoples) in the United States have long viewed human existence and the environment as sharing essential connections with spiritual, physical, and mental wellness. In Indigenous peoples’ epistemologies and sciences, humans and the physical world are one and the same; and wellness relies on the natural environment. This philosophy is passed from generation to generation.¹ Yet, AIAN peoples’ epistemologies do not regularly inform US public health or equity research and policymaking,² although there were increasing acknowledgment and calls for inclusion under the Biden presidential administration (2021–2025).³ This shortcoming is problematic, considering the persistence of health inequities associated with social determinants of health (SDOH), which were exacerbated during the COVID-19 pandemic in tribal nations and Indigenous communities.⁴

Achieving AIAN health equity requires meaningful reflection and action from national, state, tribal, and urban public health rights holders, collaborators, and decision-makers.^2,5 We share findings from the Indigenous Social Determinants Project, which was completed by Seven Directions, an Indigenous public health institute at the University of Washington. Its aim was to propose shared constructs to develop Indigenous frameworks for healing, health, and wellness by and for tribal nations and Indigenous communities. Health practitioners and policymakers may use these tailored Indigenous frameworks across sectors to strengthen Indigenous health and health-related systems, decolonize public health, and achieve health equity.

The Indigenous Social Determinants of Health Project, funded by the National Network for Public Health Institutes through a US Centers for Disease Control and Prevention (CDC) cooperative agreement, was launched before the COVID-19 pandemic and has subsequently evolved. The Seven Directions approach to accomplishing the aims of the project was value based, iterative, and participatory. The aims were accomplished in 3 phases: (1) conducting a scoping review and critique of SDOH frameworks (2018–2021); (2) listening and learning at advisory board, community of practice, and community meetings (2021–2023); and (3) developing a 6-module training pilot to test and launch an Indigenous SDOH website (2023–2024). The findings we share in this essay reflect the scoping review findings, advisory board reflections, and peer–peer feedback given during 2 sessions (March 2022 and April 2023) of Gathering Grounds, an Indigenous public health community of practices hosted by Seven Directions.

FRAMEWORKS CRITIQUE

We describe and critique existing SDOH frameworks as they apply to describing health and equity in tribal nations and Indigenous communities. Health inequities stem from policies and systems (e.g., social structure, environment, economy, health) that do not fairly distribute or provide access to resources in support of individual- and population-level health and wellness.^5,6 They are perpetuated by power imbalances and seeming lack of political will to ensure systemic changes for equity.^5,7 There are 2 standard SDOH frameworks—those of the World Health Organization (WHO) and the US Centers for Disease Control and Prevention (CDC)—which were developed to understand the drivers of health inequities.^8,9

The SDOH framework of the WHO identifies structural and intermediate determinants that create conditions for inequitable health outcomes, as shown in Figure 1.⁸ This framework’s conceptual foundation is that social circumstances (e.g., social status, cohesion) and context (e.g., governance, policies, culture, and societal values) determine the health outcomes of individuals.⁸ The identified social determinants and their pathway have equal, if not greater, impact on individual and population health than do individual genetics, health behavior, and the health care delivery systems.⁸

FIGURE 1—

World Health Organization Commission on Social Determinants of Health Conceptual Framework for Social Determinants of Health; 2010

Source. Permission was granted to reproduce this diagram as it was originally published by the World Health Organization (WHO; 2010) on page 6 in A Conceptual Framework for Action on the Social Determinants of Health.

The CDC provides a definition of SDOH as conditions in which individuals live, learn, work, and play that influence a wide range of health outcomes.⁹ They propose that 5 domains contribute to creating the conditions that define SDOH:

• 1.economic stability,
• 2.education access and quality,
• 3.health care access and quality,
• 4.neighborhood and built environments, and
• 5.social and community contexts.⁹

The conceptual foundation of this framework, based on the SDOH framework of the WHO, is that achieving improved health outcomes and equity is accomplished by using the evidence-based indicators in each domain.⁹ It is an applied framework that uses Healthy People 2030 to fulfill the functions of public health: assessment, assurance, and program and policy development.^10,11 The SDOH frameworks of the WHO and the CDC contain broad social (e.g., systemic racism, housing policies) and intermediate (e.g., living and working conditions, access to quality care) determinants of health that affect tribal nations and Indigenous community health outcomes but are limited in their relevance and applicability.^8,9,12

The disproportionate impact of the COVID-19 pandemic highlighted the need to address SDOH^4,13 and the limitations in the SDOH frameworks of the WHO and the United States. The frameworks do not consider cultural and contextual determinants such as health belief models, epistemologies, and ways of being and doing associated with healing, health, and wellness in and across tribal nations and Indigenous communities. The SDOH frameworks of the WHO and the CDC conceptually imply a linear, deterministic path to health that is individualistic rather than collective.

For more than 10 years, Indigenous scholars and global health entities have critiqued existing SDOH frameworks and raised awareness of the need to describe and map Indigenous determinants of health.^14,15 Commissioned reports described the SDOH framework of the WHO as prescriptive and unable to include the nuance and complexity of Indigenous social, political, and health realties.^15,16 There are 574 federally recognized tribal nations in the United States as well as many state and unrecognized tribes. Tribal nations and Indigenous communities have diverse histories, cultures, and traditions and unique political status and relationships with the federal government.¹⁷ Standardizing an Indigenous SDOH (IsDOH) framework would reduce the complexity and diversity among tribal nations, and specificity ensures the relevance and applicability of the frameworks. With this confirmation, Seven Directions began to identify shared constructs that might guide tribal nations and Indigenous communities in developing their own frameworks.

ENSURING RELEVANCE

From a shared understanding of the limitations of the standard SDOH frameworks of the WHO and the CDC, the Seven Directions’ team responded to calls by scholars and practitioners to go beyond social determinants and reclaim Indigenous health by identifying shared constructs of Indigenous healing, health, and wellness.^15,16

Shared determinants of health that go beyond social determinants and toward reclamation of Indigenous health need to include (1) an understanding of the legacy of colonization, (2) the healing power of Indigenous knowledge and ways, and (3) the power of Indigenous voice and participation.¹⁶ Although First Nations in Canada identified these, they are also shared among tribal nations and Indigenous communities in the United States.

In the United States, AIAN scholars of SDOH held roundtables with community members to describe IsDOH and identify areas of overlap. They created a figure that represented a typology of determinants of Indigenous healing, health, and wellness. The typology consists of broad Indigenous and non-Indigenous determinants as well as shared Indigenous and unique Indigenous determinants and health belief models.¹⁵ These were later adapted and included in the 6-module training developed by Seven Directions.

The 4 IsDOH constructs described by Seven Directions are based on the need for specificity and 3 typologies (i.e., broad, shared, and unique) of determinants of Indigenous health.¹⁵ They are illustrated in supplemental Figure A (available as a supplement to the online version of this article at http://www.ajph.org). The 4 constructs are (1) sovereignty and governance, (2) language and identity, (3) land and kinship, and (4) Indigenous knowledge and practices. All 4 constructs are understood to be relational and interconnected to create conditions for Indigenous community healing, health, and wellness.

Sovereignty and Governance

Tribal sovereignty predates European contact and has provided tribal nations the crucial status necessary to build and sustain systems that ensure the health, welfare, and safety of their communities.¹⁷ Upon the formation of the United States, Congress and the federal courts recognized tribal sovereignty as inherent to tribal nations, noting that this political status exists above and beyond AIAN racial status.¹⁷ The nature of tribal sovereignty sets Indigenous communities apart from other racial groups in the United States, both on and off the reservation.¹⁷ Citizens of sovereign nations retain rights to specific services derived from the treaties and other formal legal processes that transferred land and resources from tribes to the federal government.¹⁷

Incorporating this political status into public health approaches can serve to improve SDOH in ways yet untapped. For example, AIAN nations, in the scope of inherent sovereignty, exercise public health authority to ensure the health, welfare, and safety of their citizens.¹⁸ Tribal nations may express this authority through the adoption of tribal public health codes and cross-jurisdictional agreements that support data sharing and mutual aid with local non-AIAN jurisdictions.¹⁸

During the COVID-19 pandemic, tribal nations required masking on their lands and provided vaccines for everyone, which increased access for both enrolled members of the tribes and their neighboring communities. In some very rural areas, tribal health centers were the most accessible option for nonnatives.¹⁹ Through public health governance, tribal nations develop and provide public health and health services with Indigenous worldviews and knowledge embedded in the care, programs, and policies,¹⁸ furthering their goal of AIAN health equity.

Language and Identity

Tribal nations and Indigenous communities retain cultural and social systems, ways of being, and rich Indigenous knowledge systems that have sustained Indigenous peoples for generations.¹ However, with US colonization and assimilation policies (e.g., boarding schools, social welfare system), these systems were intentionally disrupted and, in many cases, purposefully destroyed. This resulted in a loss or dormancy of Indigenous knowledge (e.g., language, culture, practices) and identity, Indigenous health, and wellness approaches (e.g., medicines, ceremony) and the Indigenous knowledge systems or frameworks that served to connect knowledge and behaviors.²⁰ Indigenous knowledge–centered research is strengthening individual and community resilience for suicide prevention through positive coping mechanisms that come from intergenerational interactions, reconnection with culture and identity, and the resurgence and revitalization of Indigenous languages.²¹

Land and Kinship

For many tribal nations and Indigenous communities in the United States, wellness comes from maintaining geography and environmental relationships connected to collective health and healing practices.¹ The destruction and disruption of land-based wellness practices through land dispossession and removal and the destruction of sacred spiritual sites have been demonstrated to have negative health effects.²⁰ The desecration of lands contributes to a deep-seated sense of loss or grief that is felt in the collective soul of Indigenous individuals’ communities.²² In response, tribal nations and grassroots community organizations are partnering to engage youths, for example, in cultural practices that restore and maintain their ancestral connection to their lands. For example, the Healing of the Canoe study, a collaboration with Pacific Northwest Tribes, used the canoe journey as a metaphor and engaged youths in remembering and reengaging in the cultural practice for substance misuse and abuse prevention and promotion of tribal identity.²³

Indigenous Knowledge and Practices

Indigenous epistemologies include the knowledge systems based in Indigenous cultural perceptions and understandings of the world, essential elements of wellness frameworks.¹ The ways tribal nations and Indigenous communities process, understand, and teach community members about wellness relies on language, story, and practices based on ancestral teachings maintained for generations.^21–23 History serves as a cornerstone of Indigenous epistemologies and theory, as the past affects the present and future generations of our communities.²² Culturally based interventions not only add to the strength and resilience of a community but are also effective in improving population health outcomes.

The Healing of the Canoe study—an intervention aimed at reducing substance use in American Indian youths based on Salish cultural teachings and traditions—found that students exposed to their curriculum reported lower substance use rates.²³ Among AIAN epistemologies, physical and spiritual wellness are often intertwined, and one cannot exist without the other; ceremony and spiritual practices are essential to wellness.¹ Spirituality guides our understanding of this construct and conceptualization of frameworks for healing, health, and wellness and IsDOH with respect for the diversity of spiritual beliefs and practices of each Native nation and Indigenous community in the United States.^1,24

For teams engaged in developing Indigenous frameworks, the 4 constructs are a starting point for story sharing and discussions. They prompt teams to reflect on their relationship to lands, kinship, language, identity, history, and sovereignty. For non-Indigenous team members or partners, they provide an opportunity to listen, learn, and advocate. Consequently, the discussions support identifying and mapping the typology of SDOH, shared and unique IsDOH, and broad SDOH.

RECOMMENDATIONS AND GUIDELINES

Tribal nations and Indigenous communities are continuously engaged with non-Indigenous private, nonprofit, and local, state, and federal government entities. They strengthen their cross-sector, long-term collaborations (e.g., health and human services, education, judicial, environmental) to address SDOH and improve health and wellness outcomes. The strengthening of tribal and Indigenous community systems ensures the safety, welfare, and health of their citizens and community members.

The following are actionable recommendations for developing Indigenous frameworks and establishing long-term cross-sector collaborations among internal and external partners that serve tribal nations and Indigenous communities:

• 1.Establish and maintain long-term partnership built on trust, shared values, and purpose.
• 2.Develop an Indigenous framework for healing, health, and wellness for your tribal nations or Indigenous community based on meetings with community knowledge keepers, story work, and, if necessary, literature and environmental scans.
• 3.Host a community of practice or advisory board meetings to present the framework for feedback and revisions.
• 4.Work with partners to identify application of the framework. It may be applied in public health for screening and assessments, referrals and tracking, program development and evaluation, and policy development and funding allocations.
• 5.Apply and evaluate the framework.

These tailored frameworks are central to cross-sector alignment, decolonizing practices, and moving toward equity. Yet, they do not stand alone. Guidelines for integration with existing frameworks include the following:

• 1.describing health belief models,
• 2.identifying the typology of the determinants (i.e., broad, shared, or unique) and overlaps,
• 3.applying health belief models,
• 4.establishing criteria for use,
• 5.prioritizing IsDOH and SDOH, and
• 6.conducting an evaluation.

CONCLUSIONS

We have proposed the development of Indigenous frameworks of healing, health, and wellness (i.e., IsDOH frameworks) using constructs identified from scoping reviews and advisory board, peers, and community member feedback. The frameworks may be used in tandem with SDOH frameworks of the WHO and the CDC for the functions of public health (i.e., assessments, assurance, and program and policy development). The 4 constructs and subsequent IsDOH training developed by Seven Directions may be used in tribal nations, in Indigenous communities, and in partnership across sectors (e.g., public health, education, health, and social services) by practitioners and policymakers to strengthen Indigenous health and health-related systems, decolonize public health, and achieve health equity.