Decolonizing Strategies for Mentoring American Indians and Alaska Natives in HIV and Mental Health Research

Abstract

American Indian and Alaska Native (AIAN) scholars in the fields of mental health and HIV face formidable barriers to scientific success. These include justifiable mistrust of historically oppressive educational systems, educational disparities, role burdens within academe, the devaluation and marginalization of their research interests, and outright discrimination.

Research partners can work to dismantle these barriers by embracing indigenous worldviews, engaging in collaborative research partnerships, building research capacity within universities and tribal communities, changing reward systems, and developing mentoring programs. At the individual level, aspiring AIAN scholars must build coalitions, reject internalized colonial messages, and utilize indigenous ethical frames.

The creation of a cadre of AIAN researchers is crucial to improving the health of AIAN peoples.

“We must develop expert Indians instead of Indian experts.”

—Beverly Pigman, institutional review board officer, Navajo Nation

MULTIPLE FACTORS IMPEDE successful research in American Indian and Alaska Native (AIAN) communities, as in other ethnic minority groups.^1–6 These obstacles include community mistrust because of former scientific exploitation, linguistic and cultural dissimilarities, lack of culturally grounded theory and methods, and limited or selective access to community members.

As a group, AIAN researchers have distinct advantages in addressing each of these challenges. Specifically, AIAN researchers who conduct research in their own communities often exhibit high levels of interest, a sense of responsibility, and motivation to listen to community-identified needs, all of which can operate to overcome community mistrust.^1–5 These investigators may be fluent in a community's language and culture, thereby smoothing relations and increasing the validity of their work.^6,7 Finally, because they generally have greater access to the community, ability to identify community stakeholders, and experience dealing directly with tribal infrastructures and their HIV or mental health programs, AIAN researchers have the potential to increase participation and optimize retention of a broad cross-section of community members.^1–9 These advantages may better position AIAN researchers to identify key cultural constructs, appropriate theories, and acceptable intervention strategies in HIV and mental health systems of care.

Acknowledging these benefits as well as the dearth of health data on American Indians/Alaska Natives, the United Nations, World Health Organization, and National Institutes of Health (NIH) have called for increased culturally relevant research partnerships with tribal communities and the involvement of AIAN investigators.^10–13 Despite these calls, the representation of American Indians/Alaska Natives remains negligible.^6,9 Indeed, of the 35 000 NIH grants awarded in 1999, only 9 went to AIAN principal investigators; by 2006, the total was 24.^14–16 Ultimately, the dearth of AIAN researchers renders AIAN communities vulnerable to insensitive or irrelevant research and may deprive them of the benefit of culturally appropriate and empirically supported health promotion interventions.

Mental illness and HIV present great challenges to AIAN communities and require acute sensitivity from researchers. Yet, barriers to academic and professional success prevent AIAN scholars from doing relevant research with these populations. Decolonizing strategies may dismantle these barriers by “indigenizing” the academy. Given the limited research on HIV and mental illness in AIAN communities, we chose to present recommendations based on anecdotal evidence from our com-bined 30 years of experience in this field.

AMERICAN INDIAN/ALASKA NATIVE HEALTH DISPARITIES

As of 2003, there were 4.4 million American Indians/Alaska Natives in the United States from 562 federally recognized tribes.^17,18 Despite their wealth in terms of tribal diversity and cultural traditions, American Indians/Alaska Natives in the United States continue to be plagued by socioeconomic disadvantages. Compared with the US population overall, American Indians/Alaska Natives are younger, poorer, and less likely to be employed or to have health insurance.¹⁹ Moreover, AIAN populations suffer pervasive health disparities, including an unequal burden of chronic illness and mortality and morbidity from disease and injury.^13,20

The lifetime prevalence of psychiatric disorder among American Indians/Alaska Natives is 36% to 50%, with high comorbidity. Psychiatric problems, including alcohol dependence (9% to 31%) and posttraumatic stress disorder (12% to 23%) are often much higher than in non-AIAN groups.^21,22

Epidemiological evidence points to excessively high case rates of sexually transmitted infections (STI) among American Indians/Alaska Natives compared with the general population; indeed, American Indians/Alaska Natives have the second highest rates of chlamydia and gonorrhea. The potential for exposure to and transmission of HIV is greatly enhanced by these elevated STI rates.^23–25

Through December 2005, a cumulative total of 3238 AIDS cases among American Indians/Alaska Natives was reported to the Centers for Disease Control and Prevention, primarily among injection drug users and men who have sex with men.²⁶ Since 1995, the rate of AIDS diagnosis for American Indians/Alaska Natives (7.8 per 100 000) has been higher than the rate for Whites (6.4) or Asian/Pacific Islanders (4.4). Moreover, the high rates of other STIs found among American Indians/Alaska Natives and documented racial misclassification and underreporting suggest the available statistics likely underestimate the actual epidemic.^24,27

BARRIERS TO SCIENTIFIC SUCCESS AMONG AIAN RESEARCHERS

Most junior investigators aspire to the same indicators of scientific accomplishment: they strive to publish consistently in highly regarded peer-reviewed journals, to secure monetary support for their research from prestigious funding sources, and, consequently, to earn promotion through the academic ranks. However, AIAN academicians, like those from other ethnic minorities underrepresented in academe, confront additional obstacles to scientific success in their fields.

Shavers et al.⁹ identified 4 perceived barriers to academic success among ethnic minority investigators: (1) inadequate research infrastructure, training, and development (e.g., ignorance about what a fundable grant application looks like); (2) barriers to development as independent researchers (e.g., overemployment as coinvestigators); (3) inadequate and insufficient culturally relevant mentoring (e.g., inadequate access to senior investigators of color); and (4) insensitivity, misperceptions, and miscommunications (e.g., stigmatization of minority-focused research). We could find no empirical data on the obstacles inhibiting scientific success specifically among American Indians/Alaska Natives at the postgraduate level. At the graduate level, AIAN-specific barriers such as the lack of “bridging” mechanisms for competing academic and cultural worldviews and erosion in AIAN identity were identified as potential barriers.²⁸ In our experience, AIAN investigators commonly encounter or report the following barriers to success in the academy.

Justifiable Mistrust of Educational Systems and Health Research

AIAN scientists may reject health research as a career for the same reason that AIAN populations can be resistant to researchers' efforts to study them: a long history of unethical behavior and outright abuses in educational, research, and health settings. In 1879, the US government set in motion a policy that involved sending more than 200 000 AIAN children to off-reservation boarding schools.^17,29 These schools generally were located far from tribal communities, increasing AIAN children's isolation from familial and cultural sources of support. With ethnocidal intent, the boarding schools attempted to eradicate indigenous languages, cultural expression, and AIAN spirituality. By the early 1900s, more than 25 of these schools were still in operation nationwide, with continued reports of extensive physical and sexual abuse of students. Although some boarding schools continue today with greater tribal control, many AIAN communities continue to feel the deleterious effects from this era and remain openly and justifiably suspicious of educational institutions in general.

In addition to these oppressive educational experiences, some AIAN people have endured exploitation as research participants.^5,18,30 For example, among the Nuu-chah-nulth in Canada, blood drawn for arthritis research was used without their informed consent to establish ancestry,³¹ and, among the Havasupai, blood drawn for a genetic study of diabetes was later distributed without authorization for the study of other issues, including inbreeding.³² The impact of these experiences has been exacerbated by abusive health services, such as the performance of untested surgical techniques leading to permanent disfigurement.³³ Reports of these discriminatory practices spread quickly along the “moccasin telegraph” throughout Indian Country and across generations, with repercussions far beyond the immediate impact of the events.

Researchers today may approach AIAN communities with much better intentions, but if they quickly and unilaterally collect data, exiting with little or no sharing of the findings (so-called “helicopter” or “drive-by” research), AIAN communities still will fail to develop an appreciation for the benefits of health research in their communities. Understandably, American Indians/Alaska Natives exposed to these types of exploitive arrangements may become cynical about the research enterprise and reject health research as a career.

Educational Disparities Among American Indians/Alaska Natives

American Indians/Alaska Natives are the most underrepresented racial/ethnic group at every educational level in the United States.³⁴ Although over the past 25 years American Indians/Alaska Natives have nearly doubled their share of graduate degrees, currently only 0.6% of all master's, doctoral, and professional degrees are awarded to American Indians/Alaska Natives. In the life and social sciences, less than 0.003% of all doctoral candidates are American Indians/Alaska Natives. Among American Indians/Alaska Natives earning doctorates, the most popular fields are education (25%), psychology (20%), and the social sciences (13%); non–American Indians/Alaska Natives are more likely to earn doctoral degrees in the physical, biological, or biomedical sciences. Once employed, AIAN faculty, like other minority faculty, tend to focus on clinical, counseling, or administrative duties rather than research.¹⁵ For example, in 2000, only 6 of the 115 AIAN medical school faculty designated “research” as their major professional activity.³⁵

The gross underrepresentation of American Indians/Alaska Natives at all academic levels limits the pool of potential scientists. Those who do persist are stymied by a lack of visible role models. Exposed to such a small pool of AIAN faculty, AIAN students fail to receive the culturally specific support and mentorship that might further their research careers.

Role Burdens

American Indian/Alaska Native scholars may find few if any other American Indians/Alaska Natives among their immediate colleagues (i.e., they are frequently the “only one”). Therefore, they often shoulder the burden of educating colleagues and administrators about the cultural, historic, and community realities of AIAN people, a context that often is needed to understand their work in AIAN communities. They may be pressed to serve as cultural translators—explaining and justifying their work, their worldviews, and their science to a sometimes ignorant and even hostile audience.^5,7,28,36,37 Simultaneously, they need to negotiate with their own communities, explaining and justifying the potential value of Western science and education.

American Indian/Alaska Native faculty involved in their community's ceremonies may need to be present in their tribal communities for weeks at a time, often over the summer, a period when the academic calendar normally permits a more focused pursuit of research activities. Like other faculty of color, AIAN scientists often are asked to shoulder major institutional burdens and to assume administrative positions prematurely in their career trajectory.^5,8,15,28 They may have heavy mentoring loads of both students and colleagues, they informally must become “experts” on diversity issues, and they are asked to serve as liaisons between the university and tribal communities—roles for which they are often uncompensated in terms of buyout or reduction in other responsibilities.^2,5–8 These institutional role burdens can detract from the time and energy AIAN faculty could be using to develop fundable research.

Marginalization of Research Interests

American Indian/Alaska Native scholars are often intellectually, culturally, and spiritually marginalized in their academic homes.^5,7 Typically, few of their colleagues are culturally informed or knowledgeable about AIAN health issues. Fewer still are familiar with indigenous epistemologies, methodologies, and the potential burdens unique to conducting research in partnership with AIAN communities. Theoretical and methodological marginalization can stifle the academic development of AIAN scholars, who have few opportunities for the preliminary airing of new ideas, receipt of constructive feedback on pilot work, and guidance for initial research directions.^6,9 In an era when collaborative research is prioritized, AIAN scholars may find few suitable collaborators, particularly in their own departments. A dearth of qualified reviewers for their manuscripts and grant applications may further stymie their progress.

With respect to HIV and mental health research, AIAN scholars sometimes have the added burden of convincing their communities of the significance of their research. Some communities confronted by the daily impact of other health concerns, such as diabetes and alcohol use, may marginalize or minimize the need for research on STIs or mental health.

Discrimination and Microaggressions

Discrimination within university and research systems can produce terrible stress for AIAN researchers. In addition to blatant discrimination, pernicious microaggressions create insidious stress for AIAN researchers.⁵ Microaggressions are the chronic, everyday injustices that people of color endure—the interpersonal and environmental messages that are denigrating, demeaning, or invalidating.³⁸ Sue et al. grouped these as subtle dismissive microinsults (e.g., eye-rolling when an AIAN faculty member brings up issues related to AIAN communities), microinvalidations (e.g., rendering AIAN people invisible by omitting American Indians/Alaska Natives as an underrepresented group), and microassaults (e.g., making racist comments and “jokes” directly to AIAN faculty).³⁹ These types of microaggressions can trigger old wounds, residual internalized colonization, and unresolved crises in confidence, ultimately adversely affecting the academic performance of AIAN faculty.

OVERCOMING BARRIERS

Adequately addressing the barriers to scientific success among aspiring AIAN scholars will require “indigenizing” the academy.⁵ This means transforming the academy so that AIAN values, principles, and ways of relating are respected and ultimately integrated into the larger academic system.^36,37,40 This work must incorporate a rejection of the pervasive colonial devaluing of all things American Indian/Alaska Native.⁴ Central to indigenization is the process of deconstructing and externalizing the myth of the intellectually inferior American Indian/Alaska Native while simultaneously centering AIAN worldviews.^41,42

Tuhiwai Smith⁴ explained that decolonizing research is not simply about making minor refinements; instead, it is a “much broader but still purposeful agenda for transforming the institution of research, the deep underlying structures and taken-for-granted ways of organizing, conducting, and disseminating research knowledge.”^4(p88) The important tasks of indigenous research, according to Tuhiwai Smith, are developing a community of researchers focused on capacity building, developing and mentoring junior investigators, and creating the space and support for new approaches to research and examination of indigenous knowledge.⁴ To achieve success, both non-AIAN and AIAN academic personnel must contribute to this decolonizing effort.

Decolonizing Strategies for All

Embracing traditional knowledge and AIAN worldviews.

American Indian/Alaska Native communities are in the process of reclaiming rights to their own knowledge production and to science, which has been part of their communities for millennia.^38,40–44 This global indigenous scientific renaissance can be attributed to indigenous peoples' linking their liberation and wellness to the recovery and reaffirmation of indigenous ancestral knowledge. Indigenous scholars insist that the regeneration of indigenous knowledge not only improves behavioral science for all but also is the vital link to improving the health and wellness of tribal communities.

In terms of conceptual innovation, there is emerging work in trauma, mental health, and HIV research that has relevance for AIAN populations. This includes empowerment theory and the multicultural social–ecological and the ecosocial frameworks.⁴⁵ Additionally, there are new indigenist models including the process framework for decolonizing research,⁴⁶ Kaupapa Maori research methods,^41,47,48 the decolonizing framework for health research,⁴⁹ the indigenist stress-coping model,^50,51 AIAN postcolonial theory,⁴⁹ indigenous epistemology or “red pedagogy,”²⁹ the multilevel social–ecological framework,⁵² and indigenist community-based participatory research methods.^5,7 These culturally grounded approaches are relevant to HIV prevention for American Indians/Alaska Natives because they consider multiple-level factors, such as historical events and contemporary lived experiences of American Indians/Alaska Natives, as well as the “fourth-world” context of most indigenous communities.^50,51

These theoretically innovative approaches are desperately needed, as the prevailing theoretical models in HIV are based on Western disease-prevention models and focus almost exclusively on individual factors and corresponding behavior change.⁵² Similarly, research in mental health, generally grounded in Western notions, can benefit from the infusion of culturally relevant theory that is more likely to acknowledge the importance of contextual factors and the role of resilience in psychiatric disturbance.

Engaging in AIAN research partnerships.

In response to research exploitation, AIAN communities are proactively developing research for their own communities and instituting their own human participant review boards and research protocols.^5,10 They are now better positioned to engage in genuinely collaborative research partnerships with non–American Indians/Alaska Natives that will privilege AIAN experience, voices, and knowledge.^4,7,41 To guide the development of mutually beneficial research partnerships with AIAN communities, Walters et al. developed 8 guiding principles (i.e., reflection, respect, relevance, resilience, reciprocity, responsibility, retraditionalization, and revolution).⁵

Building AIAN research capacity within universities and tribal communities.

Building research capacity involves institutional investment at the federal, state, and university levels—to build a cadre of AIAN HIV researchers as well as to train non-AIAN allies in the conduct of tribally based HIV research. Capacity building also includes creating a research infrastructure that actively incorporates tribal research priorities. Researchers need to pursue more aggressively minority supplements and create postdoctoral training opportunities so that current HIV research can expand into AIAN communities. Importantly, capacity building involves more than increasing the scientific expertise of AIAN community and university-based scholars; it includes increasing the cultural humility and expertise of non-AIAN scholars. The Community Involvement to Renew Commitment, Leadership, and Effectiveness program is one potentially useful model for building tribal research capacity; it promotes a 4-step cyclical and iterative process of building relationships, building skills, working together, and promoting commitment.^7,53

Changing reward systems.

Administrators in academe and the NIH must work toward changing reward systems to value AIAN knowledge and recognize the challenges of community-based research partnerships. Reward systems should be in place to ensure that research projects are conducted with the full participation of AIAN communities. Non-AIAN principal investigators should identify and groom AIAN coinvestigators as part of a mutual capacity-building effort. At the university level, promotion requirements must recognize the extensive time commitment necessary to initiate and nurture AIAN research as well as the need for developmental work prior to intervention. They should recognize the value of innovative qualitative methodologies and technologies for intervention development (e.g., digital storytelling).

Challenging colonial research practices.

HIV researchers can challenge colonial practices by questioning the noninclusion of AIAN people in research, oversampling in studies to ensure adequate representation of American Indians/Alaska Natives for comparative purposes, reducing problems in racial misclassification by incorporating a question on tribal affiliation in studies, and, whenever possible, disaggregating American Indians/Alaska Natives in existing HIV data so that they are not lost and “othered.” Researchers also must look within themselves to identify and transform their own colonial attitudes and practices. One strategy involves regularly assessing for and publicly addressing any experiences of microaggressions among staff members.

Building AIAN programs specific to HIV and mental health.

Currently, there are no AIAN-specific HIV training programs; however, there are a few mental health–related programs that have demonstrated success in mentoring AIAN researchers. Notable programs include the Native Investigator Development Program at the Universities of Colorado and Washington,¹⁵ the AIAN Nursing Science Bridge at the Universities of Minnesota and Oklahoma,²⁸ and the Minority Research Infrastructure Support Program and the New Mexico Mentorship and Education Program at the University of New Mexico.⁸ Factors instrumental to the success of these programs include intensive mentoring by other AIAN senior researchers; the incorporation of community advisory boards, elders, and spiritual leaders as program advisors and cultural mentors; and financial support to assist AIAN faculty in buying-out time to focus on grant and publication activities. Future AIAN research training efforts should combine the strengths of mental health training programs with the HIV training programs that have demonstrated success (e.g., Collaborative HIV Prevention Research in Minority Communities Program at the University of California San Francisco⁶).

Decolonizing Strategies for AIAN Researchers

Seeking support and building coalitions.

In battling the academy, most AIAN scholars would benefit from emotional, psychological, spiritual, and social support. According to James, these are needed to navigate the “politics, inertia, narrow values, discrimination, cronyism, and corruption of higher educational institutions.”^37(p63) James further advised that American Indians/Alaska Natives on the job market carefully assess an institutional environment before accepting a faculty position, identifying trusted AIAN mentors to provide support. One strategy they suggested for balancing community responsibilities is to ask permission from community leaders for “cultural time-outs”—temporary release from some community responsibilities to devote time to research.

Recognizing and rejecting internalized colonial messages.

As noted earlier, stress and microaggressions in research settings can lead to increased self-doubt and crises in confidence for AIAN people. The key to surviving these moments is to recognize when residual internalized colonization is triggered and to name it as such so that it can be externalized and transformed. This requires a critical consciousness about the causes of AIAN oppression and colonization.⁴⁴ As Cree scholar Winona Wheeler noted,

Decolonization requires auto-criticism, self-reflection, and a rejection of victimage. Decolonization is about empowerment—a belief that situations can be transformed, a belief and trust in our own peoples' values and abilities, and a willingness to make change. It is about transforming negative reactionary energy into the more positive rebuilding energy needed in our communities.^44(p76)

Utilizing AIAN ethical frames.

Alfred⁴³ noted that for AIAN people, there are 2 ethical imperatives in their everyday conduct and lives. The “independence” ethical frame involves respecting, valuing, and honoring differences, and the “interdependence” ethical frame involves organizing one's mind and attitudes around the idea of sharing space. This includes intellectual space—Western and AIAN knowledge and methodologies. By embracing both frames, AIAN scholars can better negotiate the apparent contradictions in different epistemologies and focus their energies on identifying tools and methods that are most relevant to a particular AIAN community. Rather than inflexibly holding on to one particular tool (e.g., a qualitative approach) because it is considered the most “authentic” for American Indians/Alaska Natives, AIAN scholars can identify theoretical and methodological tools according to the needs of the AIAN community and the research at hand. Utilizing AIAN ethical frames also allows AIAN researchers to negotiate colonial authenticity challenges from the community (Can a university scientist be a “real American Indian/Alaska Native”?) and from the university (Can an American Indian/Alaska Native be a “real scientist”?).²⁸

CONCLUSION

The AIAN community and its non-AIAN allies must come together to dismantle the individual, community, and institutional barriers to academic advancement among aspiring AIAN investigators. Indigenizing the academy and providing culturally grounded mentoring are important components of this work. However, these efforts will have only limited impact if they fail to capitalize on the potential reciprocity involved in increased AIAN and non-AIAN collaborations. Yes, AIAN scholars must be nurtured and supported to succeed in the academy, yet the academy must be open to growth as well. With a wealth of traditional knowledge and a unique indigenous perspective, AIAN scholars can contribute to and even transform the academic environment and research enterprise. This transformed and unified science has the best chance of stemming the tide of HIV among AIAN communities, and, ultimately, of improving their health and well-being.