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. Author manuscript; available in PMC: 2021 Jan 1.
Published in final edited form as: J Evid Inf Soc Work. 2020 Jan 5;17(1):1–23. doi: 10.1080/26408066.2019.1617213

Family as the Conduit to Promote Indigenous Women and Men’s Enculturation and Wellness: “I wish I had learned earlier”

Catherine E Burnette 1, Rebecca Lesesne 1, Chali Temple 1, Christopher B Rodning 2
PMCID: PMC7055490  NIHMSID: NIHMS1529341  PMID: 32133410

Abstract

The purpose of this article is to explore how food and other cultural traditions promote wellness, cultural continuity, enculturation, and family resilience within tribal communities in the U.S. Using the Framework of Historical Oppression, Resilience, and Transcendence (FHORT), this critical ethnography examines Indigenous peoples’ perspectives on and experiences with food and cultural traditions. Thematic analysis of data from 436 participants (approximately 2/3rds of which were women) across two Southeastern tribes revealed a theme of “fostering the transmission of tribal knowledge and intergenerational family bonding.” Traditions such as dancing, food, sewing, beadwork, basket-weaving, music, and tribal sports were some important facets of tribal culture that participants described. Food and cultural practices promoted wellness, pro-social values, and health by fostering physical activity, traditional food practices, enculturation, and social support. Cultural practices offset historical oppression and health disparities. Programs that utilize the strengths of experiential learning through family and cultural practices are highly recommended.

Keywords: Indigenous, Native American/American Indian, Health disparities, Health Equity, Enculturation, Resilience, Wellness


The Framework of Historical Oppression, Resilience and Transcendence (FHORT), proposes that Indigenous peoples have continually and persistently demonstrated resilience and transcendence (Burnette & Figley, 2017; Goodkind, Hess, Gorman, & Parker, 2012) despite experiencing historical oppression. Historical oppression (i.e., chronic and intergenerational experiences of oppression brought on by colonization), has created a context of chronic adversity that has given rise to the health inequities. Disparities among Indigenous peoples of the contiguous U.S. (American Indians and Alaska Natives (AI/AN), to whom the scope of this inquiry is limited thus, future references are limited to these groups), have included elevated rates of substance abuse, post-traumatic stress disorder (PTSD), depression, and suicide (Masten & Monn, 2015; Sarche & Spicer, 2008). Other disparities include death from unintentional injuries (over twofold higher); diabetes (threefold higher); chronic liver disease and cirrhosis (almost threefold higher); drug-induced death (almost twofold higher); suicide (almost twofold higher); and assault (over twofold higher) than the general U.S. population (Indian Health Service, 2017).

Indigenous peoples of the contiguous U.S. represent diverse groups of 573 federally recognized tribes (Bureau of Indian Affairs, 2018), over 60 state-recognized tribes (National Conference of State Legislatures, 2015), and around 400 tribes that exist outside either jurisdiction (U.S. Government Accountability Office, 2012). Distinct historical context of colonization along with political sovereignty, based on treaty agreements with federally recognized tribes, warrants examining issues affecting Indigenous peoples separately from other ethnic minorities who do not possess political sovereignty (U.S. Commission on Civil Rights, 2004). Indigenous peoples are the original inhabitants of particular regions, and there are broadly shared experiences of colonization. Native Hawaiians are an Indigenous group of the U.S., but they operate under distinct rights in relation to the U.S. government, and are therefore not included in the scope of this inquiry.

Although historical oppression and the concomitant social changes imposed by colonization are major risk factors for wellness (Allen & Mohatt, 2014), leading to rapid disruptions in cultural continuity, Indigenous peoples have responded to and in some cases have transcended, oppression through protective factors related to Indigenous food practices and other cultural traditions (Burnette, Clark, & Rodning, 2018). Colonization is the process or means by which imperial power is established over the Indigenous peoples of an area, and can include securing ports, materials, and creating replicas of the imperial power (Smith, 2013).

The FHORT focuses on wellness, which synthesizes the mind and body to holistically prevent diseases and promote health (Burnette & Figley, 2017; Centers for Disease Control and Prevention (CDC), 2016). Many scholars agree that there is a lack of research on protective factors (Brownridge, 2008; Sullivan, Mcpartland, Price, Cruza-Guet, & Swan, 2013) and that there has been more of a priority placed on researching risk factors instead (Sullivan et al., 2013). The FHORT works from a non-linear, relational worldview, which includes holistic approaches to wellness, such as mental, physical, spiritual, and emotional realms, an approach recommended by Indigenous scholars and allies (Burnette & Figley, 2017; Fleming & Ledogar, 2008). Such approaches incorporate members of the family, extended family, and the community (Limb, Hodge, & Panos, 2008). Using this holistic framework focuses social work research on protective and risk factors is vital to the understanding the key underlying mechanisms that are contributing to Indigenous health and wellness. This research explores the specific, potentially protective factors related to family rituals surrounding food and other cultural activities. These factors facilitate intergenerational bonding through family time, enculturation through experiential learning, ethnic pride, and prosocial values. All of these protective factors are intertwined and interconnected.

Family, Cultural, and Community Connectedness

One of the most harmful consequence of historical oppression is thought to be the impairment of cohesion and communication intergenerationally (Goodkind et al., 2012). As King and colleagues go on to state (p. 81), “Colonial oppression often renders relationships and social cohesion within and between Indigenous communities fragile” (King, Smith, & Gracey, 2009). Given the social nature of Indigenous identity, feeling isolated from ethnic identity is considered a primary contributor to poor health (King, Smith, & Gracey, 2009). Historical oppression has fragmented families and communities, it has impaired parent practices and expressions of affection, and it has undermined the transmission of identity through food and cultural practices (King, Smith, & Gracey, 2009). Repairing cultural continuity for families and communities is needed to transcend historical oppression (Mohatt, Fok, Burket, Henry, & Allen, 2011).

Resilience and Cultural Continuity

Cultural continuity is a key aspect of resilience among Indigenous peoples (Allen & Mohatt, 2014). Wexler (2014) draws connections between Indigenous resilience and culture through factors related to ethnic identity and enculturation, including participation in traditional tribal activities, encompassing foodways and other cultural practices (Wexler, 2014). Bolstering unity across families and communities, largely through traditional cultural practices, is thought to be an optimum way to improve health and wellness (Hodge, Limb, & Cross, 2009). In fact, culture has been described as an antidote to poor health outcomes, despite the scant research in this area (Wexler, 2014). Cultural continuity, recently termed cultural resilience, has been found to be protective against suicide among Indigenous peoples (Chandler & Lalonde, 1998; Hallett, Chandler, & Lalonde, 2007).

Family Connectedness.

Scholars have generally agreed that family is the cornerstone of Indigenous communities (Burnette, 2017; Red Horse, 1980; Smokowski, Evans, Cotter, & Webber, 2014). Family connection and cohesiveness contribute to Indigenous resilience and resistance to attacks on Indigenous sovereignty and identity; for example, family members have refused to cooperate in oppressive systems that may improve their financial situations in the short term, but hat have threatened to undermine cultural and family unity (Gross, 2003). Moreover, Indigenous health beliefs, values, and cultural practices are transmitted through family systems that tend to be ‘close knit’ (Martin & Yurkovich, 2014). It is relevant to note that the definition of family may vary across traditions. A study of First Nations people in Canada indicated that Indigenous groups tend to have a more fluid and inclusive definition of family in comparison with non-Indigenous groups (Tam, Findlay, & Kohen, 2017). Inter-generational households, including extended family systems, are common Indigenous family structures (Red Horse, 1980; Robbins, Robbins, & Stennerson, 2013).

Family connectedness has been identified as a culturally-based protective factor against suicidal behavior and substance abuse among Indigenous youth (Goldston et al., 2008; Mohatt et al., 2011; Philip, Ford, Henry, Rasmus, & Allen, 2016). Further, community, family connectedness, family communication, and family satisfaction have all been found to be protective against suicide, substance use, and depression among Indigenous youth (Beebe et al., 2008; Freedenthal & Stiffman, 2004; Garrett et al., 2011; Marsiglia, Nieri, & Stiffman, 2006; McMahon, Kenyon, & Carter, 2012; Sarche & Spicer, 2008; Walls, Chapple, & Johnson, 2007). While some research focuses on the importance of family connectedness as a protective factor, scarce research focuses on the types of cultural and family rituals that promote and support family cohesion in Indigenous communities.

Enculturation and Ethnic Identity as Protective Factors

Researchers have recognized links between enculturation (i.e., increasing knowledge about, engaging, and identifying with traditional cultural practices), spiritual practices, and resilience (Fast & Collin-Vézina, 2010; LaFromboise, Hoyt, Oliver, & Whitbeck, 2006). A connection to traditional culture, despite the imposition of Western beliefs through historical oppression, is believed to be a protective factor for Indigenous women (Burnette, 2015a). Enculturation has been found to be protective across studies, promoting academic success and decreasing violent behavior and alcohol abuse (Henson, Sabo, Trujillo, & Teufel-Shone, 2017; Pu et al., 2013; Whitbeck, Walls, & Welch, 2012). In fact, a systematic review reported enculturation to be the most influential protective factor in fostering resilience in Indigenous adolescents (Henson et al., 2017). Indeed, enculturation has been found to promote self-esteem among Indigenous youth (Zimmerman, Ramirez-Valles, Washienko, Walter, & Dyer, 1996). Furthermore, many traditional Indigenous beliefs do not condone the use of alcohol and other drugs, thereby discouraging substance abuse (Zimmerman et al., 1996).

Stemming from enculturation, ethnic identity, or the part of one’s identity attached to a ethnic group (Zimmerman et al., 1996), has been identified as a protective factor for Indigenous youth. Expanding on this, ethnic identity is linked to a sense of belonging, shared values, and engagement with cultural traditions (Zimmerman et al., 1996). Particularly considering the disruption brought about by colonization, which undermined positive Indigenous representatives and role models (described by participants as their older family members), traditional knowledge and teachings provide the foundation for positive self-images and ethnic identity (King, Smith, & Gracey, 2009). In addition, ethnic identity is a precursor to positive mental health, and despite experiencing historical oppression, Indigenous peoples continue to transmit knowledge, traditions, values, and language to the next generation (King et al., 2009). Subsistence practices in Indigenous communities have very ancient histories (Park et al., 2016), and both social relations within communities and interactions between people and local environments through the course of subsistence activities connect Indigenous Americans to those cultural traditions and practices in the past that have shaped cultural identity in the present.

In a review of risk and protective factors of binge drinking among Indigenous youth, Tingey et al. (2016) found that traditional cultural values, strong ethnic identity, a sense of belonging related to their identity, and engaging in ethnic behavior were all strong protective factors. Further, a sense of familial belonging and parental warmth, which could aid in connection to cultural values and ethnic identity, was found in this study to be protective against heavy alcohol use (Tingey et al., 2016). Indeed, ethnic identity was found to be the strongest observed protective factor related to self-esteem among ethnic minority youth (Toomey & Umana-Taylor, 2012). Although previous research has shown that family connectedness, enculturation, and prosocial values are protective factors for Indigenous peoples against mental health disparities, there is very little research and literature specific to Indigenous groups focused on specific cultural rituals related to food and family gatherings that promote these protective factors. The purpose of this article is to explore food and cultural traditions promote wellness, cultural continuity, enculturation, and family resilience within tribal families and communities in the U.S.

Methods

Research Design

A critical ethnographic approach was used to explore what food and cultural practices may promote wellness among Indigenous peoples. Results were drawn from a larger critical ethnography identifying risk and protective factors related to Indigenous wellness. Critical ethnographies incorporate multiple forms of data (e.g., interviews, existing data, and observational methods (Carspecken, 1996)). Over 400 participants across the two Southeastern tribes were engaged in the broader ethnography through focus groups, whole family and individually-focused interviews, as well as field notes and secondary data; however, this article focuses on the interview data only. Participants spanned across professionals working in social and behavioral health, elders (55 or older), adults (24–55), and youth/adolescents (11–23).

Setting

Two tribes were engaged in the data collection process. To protect anonymity, they will be referred to as “Inland Tribe” and “Coastal Tribe.” We choose not to report the tribes’ names in agreement with tribal resolutions aimed to protect the community’s identity. For publication purposes, we have also removed details related to tribal identity, in accordance with suggestions for culturally-congruent, ethical approaches to tribal research (Burnette, Sanders, Butcher, & Rand, 2014). Tribes are distinct and represent variability across tribes and regions. The federally-recognized Inland Tribe is located further inland from the Gulf Coast. Inland Tribe has its own schools, health care and medical services, police force and other first responders, health and human services facilities, and land management agency – signs of its significant economic development. The state-recognized Coastal Tribe is located near the water, in close proximity to the Gulf of Mexico. Because the Coastal Tribe is not federally recognized, it has fewer economic resources, undermining its ability to provide tribal infrastructure for its members. However, the Coastal Tribe offers an array of programs for youth and other tribal members, including employment and educational programs.

Despite variability, both tribes have, historically, endured colonial oppression in the forms of discrimination and race dynamics of the Jim Crow Deep South. Both tribal communities have experienced severe educational discrimination as well as socioeconomic marginalization. In the period of early/mid-1900s (i.e., segregation), tribal members were completely excluded from attending schools for White or African Americans. Tribal members either received no formal education, or attended poorly resourced missionary or tribal schools that typically went through grade school. Accessibility for economic growth was severely thwarted, with tribal members subsisting as sharecroppers or living off the estuarine, riverine, and coastal environments of the Gulf South. Tribal members across communities relied on their subsistence, resourcefulness, and informal social networks for their livelihood until alternative forms of income became available in the 1970s and into contemporary times.

Data Collection

After tribal council approvals from both tribes, university IRB approval, and adult/child consent/assent, data collection for this article included gathering focus group data, family interview data, and individual interview data. The first author and collaborators recruited through word-of-mouth, social media and tribal web sites, community newsletters, and through posts at tribal agencies. A $20 gift card was provided for individual participation, and a $60 gift card was provided for each family interview. All interviews followed a semi-structured guide, and life history interviews were utilized in individual interviews, following the recommendations for culturally sensitive methods for critical ethnographies in tribal studies (Carspecken, 1996). Probes from the semi-structured interview guide included: “What do you think helps people recover more quickly from challenges, such as alcohol use, family violence, trauma, and depression? In other words, what do some people have going for them that helps them not be so negatively affected by these problems?” Participants who could be contacted received a copy of the transcribed interview. For optimum accessibility, wording was aimed for the fifth-grade comprehension level.

Sample

In total, 228 total participants from the Inland Tribe and 208 participants from the Coastal Tribe participated in the qualitative portion of the ethnography, with some participants completing more than one type of interview, adding to the rigor of the study (Carspecken, 1996). Data collection for the study included participant observation (n=58), individual interviews (n=254), family interviews (n=163 participants; 64 groups), and focus groups (n=217 participants; 27 interviews) across two tribes. Because the aim was to identify culturally specific risk and protective factors relevant to tribal members spanning the life course, we made a purposeful effort to include professionals (n=70) elders (ages 55 and above, n=105), adults (ages 24–54, n=147)), and youth (ages 11–23, n=114). Individual interviews lasted approximately 64 minutes (63.49) on average, family interviews, approximately 70 minutes (69.69), and focus groups, approximately 57 minutes (57.18). Many participants participated in more than one type of interview, and the average total length of a participant’s interview time was about 89 minutes (88.99). See Table 1 for participant demographics. Notably, 2/3rds of the sample are women.

Table 1.

Participant demographics and subsamples

Inland Tribe (N= 228) Coastal Tribe (N= 208) (N=436, 100%)
Male 85, 37.3% 63, 30.3% 148, 28.9 %
Female 143, 62.7% 145, 69.7% 286, 65.6 %
Married 62, 27.2% 64, 30.8% 126, 28.9 %
Number of children 2.53 (M) 2.57 (M) 2.55(M)
Number of siblings 4.81 (M) 4.61 (M) 4.70 (M)
Participant age (Mean) 37.1 (M) 42.5 (M) 39.7 (M)
Education (n=149) (n=158) (N=307)
Less than high school 6 72 78, 25.4%
High school 33 36 69, 22.5%
Some college/vocational 53 16 69, 22.5%
Associates 31 16 47, 15.3%
Bachelors or higher 26 18 44, 14.3%

Data Analysis

First, all interviews were transcribed professionally and checked by the research team members for accuracy, making any edits. Next, we followed a team-based analysis method due to the breadth of data (Guest & MacQueen, 2008). A separate Nvivo file (i.e., a qualitative data analysis software program) was created for each tribe and was analyzed separately. The data analysis team included the first author and four hired Ph.D. students, including one from each tribal community, increasing cultural sensitivity. The team met bi-weekly throughout analysis to enable dialogic discussion of the data and collaborative analysis. Reconstructive analysis (a type of thematic analysis) was used, which involved initial meaning construction (i.e. reading and listening to transcripts and audio files several times to be immersed in data and understand data holistically). Preliminary analysis, which involved line-by-line, low-level coding was completed, whereupon clusters of overarching codes and sub-codes were created. All team members reviewed, made suggestions, and reached consensus for the final coding hierarchy. A coding log, with all notes, decisions made, and who completed which tasks in the analysis process served as an audit trail. Cohen’s Kappa coefficients ensured interrater reliability (McHugh, 2012) at the start of and throughout the process. The coefficient was always strong or above (i.e., .80 or higher), and tended to be extremely high (.90 or above).

Next, in-depth analysis, which involved identifying explicit and implicit meanings of data was completed by providing original coding and interpretations of the data amongst the analysis team. For added rigor/triangulation, this team independently analyzed the data through the process described earlier, comparing themes with initial interpretations, in a dialogic iterative process. The first author reviewed themes, and the other team members reviewed each other’s themes, and met throughout this in-depth process. This article focuses on data about how participants talk about traditional activities. For the purpose of this article, we identified unifying themes across both tribal participants. Themes related to cultural and tribal traditions were identified across 245 sources (186 individually-focused interviews; 30 family interviews, and 17 focus groups). These themes were coded for the Inland Tribe across 101 participants (79 individually-focused interviews; 17 family interviews, and 5 focus groups) and 144 participants in the Coastal Tribe (107 individually focused interviews; 27 family interviews, and 10 focus groups). Results arose from the most frequently coded themes across tribes.

Rigor

All participants were invited for member-checks (i.e. provided interview transcripts and an opportunity to amend or correct interpretations of the results). To protect fellow-group-members’ confidentiality, group interview transcripts were not shared but descriptive summaries were. There were no changes to interpretations of results, and some participants elaborated and further confirmed such interpretations. Results were disseminated to tribes on more than 10 occasions, through: training sessions, agencies, tribal councils, community groups, and community dialogue groups (Burnette et al., 2018). Weekly peer debriefing was held throughout the data collection, and the first author ensured consistency in interviews by encouraging participants’ explanations of their thoughts and perceptions (Carspecken, 1996). Finally, almost one-third (31.6%) of participants from the Inland Tribe and almost a quarter (24%) of participants from the Coastal Tribe were interviewed two to three times.

Results

Traditions such as dancing, food, clothing, and recreational sports were expressed as important facets of tribal culture that interview participants described being inter-generationally passed down in their families and communities. Females were remarked upon as the primary facilitators of food traditions, whereas other traditions arose across genders. The following themes are identified for each respective tribe.

Fostering the Transmission of Tribal Knowledge and Intergenerational Family Bonding: Food

Coastal Tribe.

Transmitting Tribal Knowledge.

Participants shared that much of their knowledge about cooking traditional foods was learned from older family members, such as parents or grandparents, and discussed passing down the knowledge of cooking traditional foods to their children. One participant described how their aunt taught cooking with healthy ingredients:

[My aunt] taught me how to cook like all the Native dishes … it’s like all these vegetables like squash and corn, just really good. It’s good. Then you put whatever seafood you want. She taught me how to weave baskets. She just like tells me a lot of stories that like has been passed down I guess.

One participant mentioned that a family member showed them “how to cook…”, while another participant supported the importance of family gatherings where multiple generations in a family would be present:

My grandmother … I was very lucky where I had somebody to be able to show me the way [show how to do things, cook etc.], and my mom too. We would have the family get-togethers where I would go to my grandmother’s to eat on Sunday and all of that.

Fostering Intergenerational Bonding and Family Unity.

Overwhelmingly, participants spoke about how food and meals were a central point for two or more generations of a family to come together either for a special occasion or a weekly gathering. Having weekend family meals, or as one participant specified, Sunday dinners, was a prominent theme across participants’ interviews. A focus group participant recalled the following fond memories, “It was good when I was growing up. My dad [would] get off the boat … He gets off on the weekend, it was a family get-together every weekend. We threw a big [cooking celebration].” A participant from another focus group similarly shared, “Every Sunday, everyone comes here for dinner,” and another participant further highlighted the trend of Sunday meal gatherings for families, “My husband’s brother lives right there [in close proximity] … They’re real close. … They’re next door, you know? And their children come and my children come every Sunday. Every Sunday. Either he cooks or I cook.” Finally, a participant reinforced how integral Sunday gatherings with multiple generations in the family were, stating:

It’s a tradition here, every Sunday we get together … Since we lost my mom and dad, they would cook on Sunday and we’d all pile up at mama and them’s [sic] house. Talk about everything … Usually when people lose their parents the family drifts apart. You don’t see them. Ever since they [parents] died, I’ve just been trying to keep it [family] together. I’ve been doing most of the cooking, but we said we was going to take turns.

As evidenced by these interviews, designated times were scheduled for the purpose of multiple generations of the family getting together and bonding. By facilitating family rituals around cooking, communication was fostered among family members and different generations. These rituals could transcend the loss of individual family members while connecting other family members.

“Taking Care of Each Other”: Food Practices and Prosocial Values.

Participants shared how food was utilized in their community to show caring attitudes to one another. When asked what their mother was like, one participant responded, “My mom was good. Made sure we had something to eat, for sure” A focus group participant also shared about their mother, “I don’t remember my mother never [sic] having, like, ‘I don’t have nothing cooked yet.’ My mother’s house was never like that. There was always something on the stove, always. Another participant in that focus group shared that food would be ready at the house constantly because “You’re always expecting somebody.” Having food constantly available to family members or guests seems linked to the strong values of hospitality and taking care of each other in this community. This hospitality transcended the boundaries of families. One participant shared:

That’s how we are [part of tribal identity]. And when I was working at this hotel … A lot of times I’d bring food here from home and want them to try it. … They’d never heard of it and they tried, they teared [sic [enjoyed it very much]] that up. You know?

Similarly, a participant in a focus group shared this story about their mother:

There was always somebody … she could see somebody walking on the highway, years ago you know. People looking for jobs, she’d say “[name of participant] go see if he’s hungry, Look at him he probably don’t have no money.” We’d go over there and we’d ask them if they was hungry and you know then she’d feed them and send them on their way.

Not only was food prioritized to be made available for friends and family, but even to strangers in these cases. Generosity seems to be an important value that included family and members of the community. This is no surprise, since reciprocity is an important tribal value (Burnette, Sanders, Butcher, & Salois, 2011), recognizing the need to care for each other and the interdependence of all.

Inland Tribe.

Transmitting Tribal Knowledge.

Notably, participants discussed how traditions and customs surrounding cooking were passed down from older generations to younger ones. One woman shared that an older family member “…taught me to cook, she made me make biscuit and cornbread.” She learned how to make these staples when she was nine years old. The passing down of cooking knowledge at such a young age emphasizes how important food and cooking traditions are to its culture.

A participant shared the traditional ways in which their grandmother insisted they learn how to cook:

My grandma is another special person…And, um, she would teach me a lot of stuff too. I mean like cooking outside…. But it was more like she told me, “You’ve got to learn how to do all this because you never know you might not be able to afford electric, you know, at a time.” I mean, things that my elders taught me, I take it to heart now because back then it was like, well, that’s not gonna happen but it is happening.

Another shared, when asked what their grandmother taught them growing up, “I think all the foods that I can cook I, I learned it from her.” Finally, a participant discussed their mother cooking a traditional dish called hominy: “She used to get this big old wooden thing and beat it, get all that yellow, sh- I guess, I guess it’s called, the yellow part on corn?”

It is evident from these interviews that older generations in families pass down cooking traditions and, in some cases, traditional ways to cook their Tribe’s cuisine.

Fostering Intergenerational Bonding and Family Unity.

As with the prior tribe, participants discussed themes around how cooking and food were utilized to promote intergenerational knowledge and bonding amongst multiple generations in a family or the Tribe. One participant highlighted that intergenerational bonding occurred around meals and food gatherings:

My mom’s house was actually the house that everybody came to eat for holidays, birthdays. It was always a big thing for her because she would cook outside and she’d invite everybody… My grandma was the backbone, but my mom is the oldest child. … She’s always felt like she has to bring [the family together].

Other participants highlighted the importance of family gatherings, with one individual noting “It was, you know, grandma was the main cook, and everybody goes to work … And everybody would just gather at grandma’s house for supper.” Similarly, another participant recalled, “every day, at 4:30, when we get off work we’d go to mom’s house because she’d have supper ready.”

These memories highlight how traditions around cooking and food in these two tribes have served as rituals that promote family cohesion and resilience.

“Taking Care of Each Other”: Food Practices and Prosocial Values.

Participants spoke about how cooking and food could be used to show hospitality, generosity, and affection to members of their family, friends, and the community. One participant responded with the following when asked about how their mother treated people:

How she cared for them and she could tell if you hadn’t eaten before, and she always cooked a big meal because there was a lot of people that lived in the house. There was always leftovers. If one of their friends or one of my friends came over they just probably stopping by and she’ll ask them. She’ll fix you a plate and stuff like that.

Participant 122 was asked if they ever were hungry when they were younger and responded with “No, because we always have food.” This indicates that food was a source of stability and may serve as a protective factor to offset low socioeconomic status. Similarly, Participant 157 said “Yeah, and I could never say that, you know, we never went hungry … Because she [family member] was mainly, uh, you know, in the garden or… You know, she, she was smart too, um, as far as financial goals. She was taking care of all of that.” Participant 144 elaborated on getting together for meals as a time to comfort one another:

I know with my immediate relatives here, I think, you know, year in, year out, um, we look forward to the holidays. It don’t matter what it be, you know? It could be spring break or whatever, but they’ll say, “Hey, let’s have a cookout on the weekend, you know, come together.” And we’re coming together just sitting there, talking, and there’s no alcohol, nothing involved, you know, at these places that we’re going to. So, you know, going to someone else’s house, cooking, you know, traditional foods and all sorts. It’s been a big help to me… If there’s, if anybody has a problem, it’s kinda like an open discussion almost, you know? We try to problem solve with each other.

Having discussions or sharing problems with family members was a natural occurrence while sharing food with family. In this particular case, the absence of alcohol is important to note, as it promotes healthy community and family behaviors. Passing down knowledge about traditional cooking would at times coincide with passing down knowledge of culture and the historical way of life for the tribe, to which the focus now turns.

Fostering the Transmission of Tribal Knowledge and Intergenerational Family Bonding: Cultural Practices

Coastal Tribe. Community Events.

Along with family meals, many participants identified community gatherings as an important and enjoyable component of life with their family and culture. These gatherings consisted of traditional ceremonies, pow wows, tribal council meetings, and educational events. Participant 1003 and others discussed their family’s participation in such events, which seemingly led to their own involvement, stating “I do the committees; I sit on almost all of the [tribal] committees.” This participant added, “When I moved in with my dad we were going to meetings … I remember going all the way to [nearby city] to go sit a tribal council meeting. He taught me the politics side of it … Every meeting, he had me there.” Likewise, participant 1014 shared:

Well, my aunt she’s the main one that’s kept me like, not in line, but like in that area for sure because she’s like [the] Vice Chief. She’s been on the [tribal] council for like her whole life. Our grandma, I don’t really remember her too much, but apparently she was the same way. That’s where my aunt got it from just being in the [tribal] council and just doing stuff for the tribe.

Pow Wows and Dancing.

Along with community meetings, traditions surrounding music and dance were discussed as positive activities that participants enjoyed. A pow wow is a North American Indigenous celebration, which involves dancing, drumming, singing, and community; typically alcohol is prohibited at these events. Participant 1011 talked about family involvement with pow wows, stating “My dad’s been all the way to Canada. But we’d go all over. He had a drum for a while and we would sing on a drum and dance. Have our own regalia and everything.” Participant 1011 went on to recall the commonality between pow wow culture and food sharing practices:

When we were little, and they would have drum practice at each drum member’s house, and we would all bring food. Everybody would bring something, so we would have something to eat. The adults would sing most of the time, and the kids would be off in the room or something playing. But, as we got older, I would sit on the drum, and I like singing … Oh, I love it. I always say that being around that circle, and singing and having all those voices and everybody, it’s just… it’s so powerful. You just have this feeling inside of you that I always say that I’ve never… nothing else has ever made me feel like that. At the end a lot of times, everybody will put their hand on another person or something, and you just feel that energy.

This participant indicated not only that they enjoyed and valued the act of participating in the singing circle, but coming together with other family and community members appears to be of importance. Participant 1094 shared “Where I grew up … I was in a dance group …so we had to make our regalia [outfits for pow wows] and it was just something I picked up. I used to love making the earrings and the medallions.” Similarly, a participant from a family interview recalled fond memories of larger family involvement which centered around traditional activities:

It was a family affair to get their regalia together … the grandparents, the parents, the children. Everybody was involved. My mother and her sisters would come to the pow wows … everyone, yes and they loved it. They loved to go to pow wows. I have pictures of them sitting around waiting for [family member] to go on. Waiting for them to dance … He was raised with the pow wows since the age of three.

Beadwork, Basket-weaving, and Sewing Traditions.

Beading and basket-weaving were common tribal traditions participants discussed. Participant 1003 spoke about various practices learned from earlier generations. “My aunt – we lived next door – and she was always on a mission to teach me beading and basket-weaving and things like that. I knew everything that I knew from her on that side.” Participant 1087 also recalled family involvement in traditions. “We’d go to my cousin’s house. … We’d go over there and they would help my mama. My mama and my grandma would help her with some quilts.” Participant 1040 reminisced “I remember when I was a kid … the elders would teach us how to make like the baskets and the dream catchers and things like that. You just don’t hear about that these days.” A focus group participant shared, “I learned from my grandmother and my mom. She says it’s time to pass it down. She actually picked up on [tribal member’s] basket weave.” When prompted on things they enjoy and how they learned them, they stated “knitting … [I learned from] my aunt … it’s relaxing.” A participant from of family interview shared the following memory of their grandfather:

I think the most happiest [sic] time I had was when we went to see my grandfather. … He built a house. My grandfather was a trapper. My grandmother was a cook … I remember sitting on my grandfather’s lap. The rocking chair that he made – the porch that he built, him singing songs to me and telling stories.

Several individuals discussed learning through community events. A focus group participant shared, “the library teaches on Fridays basket-weaving.” Another focus group participant shared whether she enjoyed this activity, stating, “I am [enjoying basket-weaving]. Yes. I love it.” Other responses included “what I like about this program that I learned how to do the ‘7 braid’ and I learned how to do different things like the ‘4 braid,’ too” adding “I was able to enjoy my time with my daughter learning together this stuff.” Participant 1016 shared their experience with crafting in the community center. “Weaving? Yes I did. I did it when I was at a community center. I did the weaving. I did that for a while just for fun.” A focus group participant took great pride in her grandmother’s weaving talents, recalling:

My grandma don’t [sic] know how to read, and I can tell you right now you can go to the Smithsonian and you can see her basket. She didn’t know how to write her name, she didn’t know how to read, but she knew how to make a basket, and that’s how she did.

Participant 1017 stated, “I know how to do the basket-weaving. I know some medicines. Some herbal medicines. I know some of that … I know how to harvest everything that you need for the baskets. I know how to do all that.”

These participants placed value both on the knowledge itself and the method of attaining these values. Learning and connecting with other generations was a common thread which added value to the knowledge gained as well as the memories the experience of learning created with family members.

Inland Tribe.

Like the prior tribe, many participants fondly recalled memories of learning from their elders. Participant 182 shared that their father, “Taught me art, he taught me music. He was the one who … taught us to see the world in a different way.” This statement indicates that the participant not only values the skills that the father passed on, but that it profoundly shaped who that person was. Participant 122 stated that they spent a lot of time with their grandfather, and that this time was often spent learning new skills.

Pow Wows and Dancing.

Participant 135 mentioned that though they enjoyed playing a traditional tribal sport (The name of the specific tribal sport has been left out to preserve anonymity of the tribal community(s)), “my grandma didn’t really like me playing [tribal sport] because it was a rough sport and so basically, that was about it. It was mostly dancing.” Participant 207 explained,

I was at a powwow when you called me. My grandson was dancing. Yeah. He’s a dancer. Yeah. It helps him you know occupy, he makes his own beadwork. And so then we try to help out with his other activities, you know, that puts together. Keeps him busy and the school. I really think that, you know, it helps him to be away from alcohol and drugs so anything I can do to help him to help him be a dancer. And he loves dancing. We go to a pow wow, he says, ‘I can’t wait to dance,’ and it fills my heart to hear that.

In this tribe, the traditional social dancing was still present, including the dancing for different tribal festivals throughout the year. Pow wow dancing is practiced across the U.S. and across tribes, and often tribes have tribal specific dancing practices as well. As Participant 175 recalled,

Ever since I was real little, my uncle- I have cousins that are the same age as me and one’s older- a year older, but he had started when we were 4 or 5 a- a dance group, traditional dance group, and I’ve been dancing with them. I still do.

When asked about a tribal strength, Participant 203 responded, “Dancing. The children love to dance. The spring festivals or [tribal specific festival], They love to do that. [They] Dress in their traditional um regalia and stuff like that. I’m proud.” This participant thought the dancing was good for tribal members’ ethnic identity development.

Beadwork, Basket-weaving, and Sewing Traditions.

When asked the types of things that they learned, a focus group participant mentioned that they learned beadwork from many generations, “My mom. My aunt. And Grandma. Myself.” A family interview participant expressed:

“[Family member] taught him how to make baskets. She’s trying to teach him and they went and cut cane. They trying to help them learn how to make baskets. There’s usually the girls that learn, so I know, my mom knows, my grandmother her mother, now my daughter knows how to make it. Then now we got to teach the grand babies. We just go on from generation to generation over time. My brother learned how to make it and my other brother learned how to make it. But usually when, that’s something to be proud of when we hold that generation thing going. Now everybody teaches everybody.”

One focus group participant described the tribal culture passed down and taught in their communities, families, and school programs, “It’s not just a language, it’s more like traditional dancing and sports like [tribal sports game], games, and stuff like that. Those are introduced at young age.” Another focus group participant further elaborated on this describing the importance of tribal cultural clothing as well, “[The school program] has arts and crafts and dresses and shirts being made. It’s really unique with those dresses, how they make them.”

This type of intergenerational learning appears to hold a great deal of importance to participants. Not only does it strengthen relationships among family members and across generations, it provides individuals with a sense of pride and identity related to their culture. Having this experience themselves allows them to appreciate its significance and the ability to provide future generations with a similar experience.

Participant 113 expressed, “I like getting to make things … We made the baskets, we made our own shirts, and we got to make our own designs on it. We learned how to make designs for our regalias and stuff like that.” Regardless of the method or reason for crafting, participants all demonstrated that it is an enjoyable activity which aided in feelings of connection to their culture and family. Similarly, participant 107 recalled that some memories of their mother were that she was “basically just home making and making [sic] cultural clothing.”

In addition to traditional sports and crafts, participants identified dancing as a meaningful pastime.

Tribal Sports Related Activities.

Family involvement and intergenerational themes are present in traditional tribal physical activities and sports, which not only included playing the sport, but making the equipment for the sport. Participant 122 shared that in addition to bead work, they make the equipment for the tribal sport, which they stated “I learn from my grandpa. Old grandpa [sic].” Participant 4, when asked about their favorite thing to do as a family, responded, “Go on vacation [sic] … We went to go play [tribal sport].” Moreover, participant 159 mentioned that they enjoy making sticks for [tribal sport], “just so I can make my own.” Participant 7 stated that while they did not do any of these crafts themselves, that their father used to make equipment to play [tribal sport]. They shared, “I’d like to learn but I just can’t go to the woods, and, you know, get my own trees … I wish I had learned earlier in my, you know, in my younger days but I never did.”

Participant 182 recalled their grandfather’s contribution to the current popularity of [tribal sport] in this community. They stated that their grandfather “announced at the [tribal sport] games… He brought [tribal sport] back. So, he was known for a lot of stuff.” Based on this discussion, the participant seemed to exude pride in their grandfather’s achievements. Participant 188 noted that a favorite memory is “probably playing [tribal sport] with my dad… it’s fun, but it gets serious.” These participants reminisced on fond memories of recreational activities which included family members. Finally, a family interview participant discussed the variety of ages that participate in [tribal sport] in the community: “There’s little kids, big, junior boys and then adults. Well, not just junior boys, girls play, too.” Thus, although this is traditionally a male activity, it has become inclusive of males and females. The range of ages involved in these activities indicates the importance of passing down a time-honored tradition across ages and genders. Participation in these types of intergenerational activities may also augment cohesion, support and understanding among families and communities.

Discussion

Food and other cultural practices fostered the transmission of tribal knowledge along with intergenerational family bonding across both tribes. Older female family members tended to transmit knowledge about traditional tribal foods and cultural practices. Importantly, food is considered at the center of Indigenous culture (Centers for Disease Control and Prevention (CDC), 2013). Approximately 60% of the current world supply of food is thought to have originated from North America where Indigenous peoples had already developed an abundant supply of nutritious food, including many varieties of corn, beans, and squash (Park, Hongu, & Daily III, 2016). Indeed, the CDC has supported the Traditional Food Project to promote health and prevent Type II Diabetes through the reclamation of traditional foods that promote enculturation and health (Centers for Disease Control and Prevention (CDC), 2017). Female tribal members in particular tended to carry food knowledge and be the preparers of food, which served as an important glue holding the families together through rituals and meal sharing. Burnette (2015b) indicated an important finding on the role of women in traditional cultures states that “the centrality of Indigenous women was embedded within Indigenous spiritual practices and beliefs, which maintained social order and enhance cultural synthesis.”(p. 3).

Family connectedness was prominent in results and has been found to be a protective factor against suicide, depression, alcohol use, and violent behaviors among Indigenous youth (Henson et al., 2017). Specifically, a study that used the National American Indian Adolescent Health Survey found that involvement in traditional activities as a form of experiential learning was found to protect against suicidal attempts and ideation for Indigenous males (Pharris, Resnick, & Blum, 1997). Further, a study highlighted that when examining individual elements of enculturation, participation in Indigenous traditional activities had significant positive effects on efforts to end alcohol consumption (Stone, Whitbeck, Chen, Johnson, & Olson, 2006).

Families tended to get together regularly for meals, especially for Sunday dinners and for holiday meals. Living in close proximity to family members was crucial to facilitating this regular interaction with family members. Elders play an important role as the backbones of families by teaching various aspects of Indigenous culture to family members, including tradition, history, and Indigenous values, which have been found to be protective (Burnette, 2017). When elders and other family members died, the ritual of sharing meals could keep family members in close connection. Time spent sharing meals also facilitated communication, which enabled discussions about life and collective efforts to solve problems and to resolve or manage interpersonal conflicts. The existing literature does suggest that family rituals serve as important functions for families and promote group membership and a sense of belonging (Fiese, 1992; Fiese, 2006; Imber-Black, 2003; Mead, 1973). Fiese (1992, 2006) states that the symbolic component of these rituals instills group identity through the building of shared meanings across time. Rituals, therefore, represent and convey messages of the family’s values and beliefs about the world, other people, and the family itself, and that all of these are passed down through generations (Fiese, 1992; Fiese, 2006). A systematic review reported that routines and rituals were prominent factors related to resilience among families, although this review was not Indigenous-specific (Black & Lobo, 2008). Longitudinal research supports the importance of family meal frequency, indicating its long-term protective effects against female, but not male, substance abuse among non-Indigenous adolescents (Eisenberg, Neumark-Sztainer, Fulkerson, & Story, 2008). Indeed, the frequency of family dinners has been found to be a protective factor that may curtail high-risk behaviors among youth (Fulkerson et al., 2006).

Sharing food was also an important value of hospitality, stability, generosity, and caring for each other and community members. Being able to count on those who tended to make meals (i.e., female family members) added to the sense of security and could offset economic insecurity. Extant research has indicated that family gatherings are positive traditions in Indigenous women’s lives, and thus act as an instrumental buffer for women who have experienced intimate partner violence, or IPV (Dalla, Marchetti, Sechrest, & White, 2010; Walters & Simoni, 2002). These types of family rituals have been found to increase family cohesion and unity while also providing opportunities for enculturation (Robbins et al., 2013). These rituals of extended family gatherings have been recognized as opportunities to discuss problems with family, thus increasing family connectedness and acting as a protective factor against suicide attempts (Borowsky et al., 1999). Parent-child communication, prosocial parental values, and family relationships have also been linked as protective factors for Indigenous youth related to mental health, suicidal behavior, and substance related outcomes (Henson et al., 2017).

Along with food, tribes facilitate cultural practices. Enculturation provided exposure to tribal beliefs and storytelling. Enculturation may have an indirect impact on overall mental health due to social support found in tribal engagement and activities such as pow wows (Burnette & Figley, 2016); conversely, disconnection and isolation from family and community was found to be a significant risk factor for suicide among Indigenous youth (Grossman, Milligan, & Deyo, 1991). Inland Tribe participants spoke more about community events, such as tribal council meetings, and how family members exposed them to such meetings, which helped future leaders to feel comfortable fulfilling these needed leadership roles. Pow wows and related activities of dancing, making regalia, and drumming tended to promote family bonding, were alcohol-free, and fostered connectedness for both men and women across both tribes. These activities provided positive opportunities to promote ethnic identity in prosocial ways, which is especially important for Indigenous youth (Burnette & Figley, 2016; & Liddell & Burnette, 2017). Studies have found that Indigenous youth valued their traditional culture, thus were open to enculturation, but a large portion felt that they did not have regular access to participate in cultural activities (L. M. Wexler, Dam, Silvius, Mazziotti, & Bamikole, 2016). Henson et al. (2016) assert that “the need to support and invest in Indigenous culture preservation and revitalization efforts are critical to ensure Indigenous adolescents have access to uniquely tailored protective factors only their cultures can provide” (p. 21).

Similarly, beadwork, basket-weaving, and sewing traditions were prominent across tribes, enhancing family bonding and enjoyment, ethnic pride, and cultural knowledge, especially for female members. Baskets are individualized for each tribe and are a core part of tribal identity (Indian Country Today, 2013). One participant mentioned, despite a grandmother not having formal education (as a result of educational discrimination and segregation), she could make the highest quality of baskets, adding to her ethnic pride and self-esteem. Because of historical oppression, many tribal members may have been excluded from formalized opportunities for higher education and economic mobility (Burnette, 2015b), yet have maintained and developed alternative avenues for stability and pride through food and cultural activities, such as basket weaving. Such activities were often listed among participants’ most fond memories.

Communities also promoted such activities, where tribal members could engage in practices with or without their family members. Community programs are particularly important to offset any loss of cultural traditions due to historical oppression, effectively filling the resultant ‘cultural gaps’ that may have been formed as a result of such oppression. The Inland Tribe still retained a strong tradition of tribal sports activity, which naturally promoted tribal knowledge, family involvement, community connectedness and physical exercise. Additionally, such sporting activities promote a sense of ethnic identity and are pathways to share tribal values, teachings and traditions (Zogry, 2010). As aforementioned, this offsets feelings of isolation from one’s ethnic identity, which is a primary cause of poor health (King, Smith, & Gracey, 2009).A particular traditional tribal sport was prominent among the Inland tribe. In a study which drew connections to the overall health of Indigenous peoples, Bersamin et al. (2014) found that not only do Indigenous communities have some of the lowest rates of physical activity of all other ethnic groups in the U.S., but that this is due in large part to a loss of culture. They point out that many traditional activities, such as hunting, traditional food and medicine, and engaging in spiritual practices, are all connected to higher levels of physical activities. This finding suggests the health benefits of enculturation may be connected to both physical and mental health, which can impact each other. In fact, the findings from this study indicate that those engaging in traditional lifestyle activities were more physically active and endorsed lower levels of psychosocial stress (Bersamin et al., 2014). Traditional tribal sports may be one avenue to promote wellness.

The themes surrounding food traditions and rituals in this research study were related to passing down cooking culture and traditions, fostering intergenerational family unity, and facilitating pro-social and generosity tribal values. Generosity, sharing, and giving are fairly consistent Indigenous values, and these values can be very protective if passed down in generations and honored within families and communities. Grobsmith (1981) describes the phenomenon of giveaways, which is the notion that if one member of a family network has a resource such as a bar, housing, or food, that resource is available to all family members no matter what. Prestige and social security are gained in communities by showing generosity to friends, neighbors, and even strangers. Families living in extreme poverty may express generosity by redistributing possessions; in return, that family earns respect and that generosity will likely be reciprocated when their time of need approaches (Grobsmith, 1981). Since giveaways are viewed as genuine generosity and not a display of ego, the giveaway system creates networks that nurture mutual aid during difficult times (Brokenleg, 1999). Thus, through the value and practice of generosity, along with other pro-social values connected to food traditions, family rituals, and other cultural practices, families act as a conduit to promote enculturation and wellness.

Limitations and Future Research

Although we argue that the use of two tribal case studies enables a more nuanced ability to compare and contrast differences in risk and protective factors between tribes, we are limited in our ability to draw generalizations to other tribal populations. Other important tribal traditions, such as language and subsistence were not included in this inquiry, and their significance warrants separate inquiry. Future research would require applying this inquiry to other specific tribal contexts. The process outlined in this paper shows the importance of a sustained research method built on trust and the respect of tribal insiders, but the details such as sample size, outreach and follow-up methods will differ by tribe. Replicating research would be highly unlikely without prior long-term relationships with each tribe.

Although our interpretations of data presented here demonstrate resilience within tribal communities related to subsistence living, there is also data about health disparities between Indigenous communities and the larger American population. Negative news about health issues in tribal communities receives more media attention, perpetuates negative stereotypes, and contributes to subtle forms of discrimination (Fast & Collin-Vézina, 2010). Yet, more bridges in research are needed to facilitate a balanced perspective, taking into account the devastating impacts of historical oppression, while acknowledging the variability across tribes and the resilience and transcendence demonstrated by Indigenous peoples (Burnette & Figley, 2017; Fast & Collin-Vézina, 2010).

Implications and Conclusions

Findings from this study indicate that more grant funding geared at promoting the infrastructure and resources available for existing social networks is needed to bolster the legitimacy of such sustainable communities for health and wellness. Federally recognized tribes have some infrastructure that can be enhanced through federal and state initiatives, funding, and resources geared at promoting tribally-based programs and policies. For example, in 2008, the CDC provided funding for the use of traditional foods and sustainable ecological approaches to promote health and wellness with 400 tribal leaders across 171 tribal nations (Satterfield, 2016). Results from this project emphasized (Satterfield, 2016): (a) the significance of land and subsistence; (b) food sovereignty movements; (c) respect for traditional tribal knowledge; (d) the importance of tribal values; (e) elders as teachers fostering intergenerational relationships; (f) community education of traditional foods; (g) community-based efforts; and (h) sustainable initiatives.

Thus, although most funding entities focus on formal services for Indigenous communities, more attention to promoting health within the existing social networks and community-based health initiatives is warranted. Given some traditions tend to fall along gender lines, these programs should be created with gender in mind. For example, Pollack (2016) observed a project which implemented talking circles in a women’s prison in Canada and incorporated First Nations and non-First Nations participants (Pollack, 2016). Participants shared that this program provided the opportunity for personal growth related to self-esteem, sense of belonging, family relationships, personal agency, attitudes, and positive behavior (Pollack, 2016). Schulz, Walters, Beltran, Stroud, and Johnson-Jennings (2016) note that “experiential learning reverses a traditional sequence of information assimilation” (p. 25). In their study, members of an Indigenous tribal community walked the Trail of Tears to address the impact of historical trauma on community and tribal health (Schultz, Walters, Beltran, Stroud, & Johnson-Jennings, 2016). This holistic approach to understanding and learning not only affected participants’ understanding of health, but also resulted in a change in attitudes and behaviors (Schultz et al., 2016). Finally, Simpson (2004) notes that the type of Western learning concerned with written as opposed to oral documentation is attached to a privileged, colonial way of thinking. She suggests that reconnecting to traditional processes and traditions of Indigenous knowledge will aid in the recovery of Indigenous culture as a whole (Simpson, 2004).

Preserving, protecting, and promoting health though holistic and culturally grounded mechanisms should be prioritized in policies affecting Indigenous peoples. Tribal and community leaders, as well as allies, can voice these policy initiatives at federal and state-levels. Interventions seeking to bolster these natural protective factors and resilience of Indigenous communities are recommended. In closing, holistic approaches to health that include mental, physical, spiritual, social, and emotional dimensions are recommended (Burnette & Figley, 2017; Fleming & Ledogar, 2008). Incorporating cultural traditions and members of the family, extended family, and the community are vital to addressing disparities in an effective and culturally relevant way. Such approaches can promote enculturation and a sense of belonging through ethnic identity, they can offset historical oppression, and they can promote health and wellness for Indigenous peoples.

Acknowledgements:

The authors thank the dedicated work and participation of the tribes who contributed to this work. This work was supported by the Fahs-Beck Fund for Research and Experimentation Faculty Grant Program [grant number #552745]; The Silberman Fund Faculty Grant Program [grant #552781]; the Louisiana Board of Regents; the Newcomb College Institute Faculty Grant at Tulane University, University Senate Committee on Research Grant Program at Tulane University, the Global South Research Grant through the New Orleans Center for the Gulf South at Tulane University, The Center for Public Service at Tulane University, and the Carol Lavin Bernick Research Grant at Tulane University. This work was supported, in part, by Award K12HD043451 from the Eunice Kennedy Shriver National Institute of Child Health & Human Development of the National Institutes of Health (Krousel-Wood-PI; Catherine Burnette-Building Interdisciplinary Research Careers in Women’s Health (BIRCWH) Scholar). Supported in part by U54 GM104940 from the National Institute of General Medical Sciences of the National Institutes of Health, which funds the Louisiana Clinical and Translational Science Center. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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