Intertribal Collaboration and Health: A Literature Review

Abstract

In the United States, American Indians and Alaska Natives (AIAN) are rebuilding their nations through assertion of sovereignty, standards of governance, cultural frameworks, strategic orientation, and effective leadership. The approach emphasizes tribal self-determination in managing nation affairs and reducing reliance on state and federal assistance. Through nation-building, tribal nations can improve their citizens’ health and well-being while empowering local capacity and cultural pride. Intertribal collaboration can be an effective strategy to leverage resources and create a coalition for support and knowledge exchange; however, the research documenting practices, and outcomes of tribal health management that uses intertribal collaboration is limited. This systematic review investigates health-focused collaborations among the tribal nations in North America. Peer-reviewed articles that included at least two federally recognized tribes, described AIAN driven initiatives, implemented a health management plan, collaborated between Indigenous leaders, and goals of social, behavioural, mental, and physical health outcomes were examined. This search was limited to articles published between January 1, 1970 to November 30, 2019. The PRISMA systematic review process was used. Twenty-seven articles were screened, and three articles were eligible for thematic review. The articles highlighted the importance of utilizing an Indigenous framework to facilitate program management and collaboration, recognition of cultural differences, and sovereignty rights. Characteristics that contributed to the establishment and strengthening of intertribal collaboration were: (1) adapt new proposals, (2) respectful recognition of sovereignty, and (3) transparent and honest communication. The small sample size indicated most Indigenous health programs are not “AIAN-driven”, limiting the foundation for building evidence-based frameworks.

Introduction

Intertribal is an occurrence involving two or more tribes. The National Congress of American Indians (NCAI) uses the term “intergovernmental relationship” to propose a form of intertribal collaboration. In this context, a collaboration between tribal and state governments is intended to increase awareness among both forms of government and their benefits of intergovernmental coordination on justice issues (NCAI, 2019). In other words, intergovernmental relationships are important collaborations to overcome tribal-related challenges (Randall & Cote, 1991); however, intergovernmental relationships are partnerships between AIAN tribes and outside sources with no indication of intertribal connections. Intertribal relationships are scarcely discussed in the literature. Relative to health, the foundational characteristics of intertribal collaboration needs to be defined and explored as a resource to support the health and wellness of tribal citizens. To understand the relationship among tribal nations is through tribal sovereignty. Tribal sovereignty is the concept of the inherent authority of tribal nations to govern themselves within the borders of the United States (US) (US Department of Justice, 2019). According to Henson and Taylor (2008), tribal nations aim to: (1) strengthen their institutions of governance to more effectively assert their sovereignty; (2) diversify their economic activities to improve citizens’ well-being; (3) craft innovative social policies by drawing upon the experience of both the Indian and the non-Indian worlds; (4) develop cultural resources – both traditional and emergent; and (5) provide strategic orientation. These five objectives describe the process of Indigenous nation building and support Guetzkiw’s (1957) broad definition of inter-nation relationships. This literature review explores the links between intertribal collaboration, health management, and public health as documented in the peer reviewed literature.

Background

The total AIAN population is 2.9 million, approximately 1 percent of the US population (NCAI, 2019). Seventy-eight percent of AIAN people live outside their predefined borders, as many urban areas are historically known as their ancestors’ tribal lands (OMH, 2017). In the US, there are currently 573 federally recognized AIAN tribes and an additional 100+ state recognized tribes (OMH, 2017).

AIANs are considered a vulnerable population, especially within health research. Majority of AIAN research projects are led by non-AIAN investigators. Past and present research practices often compound the impact of colonization, historical trauma, and highlight health disparities as opposed to leveraging the protective factors among AIANs. Additionally, limited leadership engagement impedes tribal communities’ independence from outside sources. Robbins, Stare, and Riggins (2019) conducted a community-based psycho-educational group training program for substance abuse disorders and found AIAN communities’ active participation and collaboration in health research can overcome limited participation in study. Thus, health research tribal leadership may contribute to intertribal collaboration and health management and public health efforts.

“Tribal governments shape AIAN values and influence most issues within Indian Country. Tribes have the inherent power to govern all matters including their members. Tribal governments exercise their authority through developing specific procedures, establishing civil and criminal laws, and maintaining appropriate regulations (e.g. judicial systems, infrastructure)”

(NCAI, 2019).

Health disparities and inequities in AIAN communities are direct products of federal policies limiting tribal powers, economic development, jurisdiction, cultural lifeways, and decision-making (Warne & Frizzell, 2014; Jorgensen, 2007). Currently, tribes are in an age of nation rebuilding, that depends on tribal governing structures’ ability and action to assert and protect tribal sovereignty and strategically develop tribal programs, institutions, and regulations (Jorgensen, 2007). Aspects of tribal sovereignty and self-determination are recognized as strength-based approaches in public health interventions, tribal wellness, and leadership; however, the potential and effectiveness of nation-to-nation (intertribal) collaborations has gained attention and should be explored as a resource in health intervention, management, and public health. Jorgensen (2007) has argued that programs and institutions that are culturally appropriate and tribally initiated are highly sustainable and innovative. To achieve intertribal collaboration, the need for intersectoral collaboration may benefit many AIAN communities and the opportunity to share resources (Jhang, 2011).

Methods

A literature review was conducted to document the representation of intertribal health collaborations in the peer-reviewed literature. Search terms included: intertribal OR multi-tribal OR tribal OR native AND Indigenous OR American Indian OR Native American OR urban native AND collaboration OR partnership OR consultation OR advising OR cohesion OR CBPR OR network AND health impacts OR health outcomes. Indices searched included: PubMed, CI-NAHL, SocIndex, ERIC, PsycInfo, Bibliography of Native North Americans, and BioMed Central.

Literature was included according to the following inclusion criteria: (1) described at least 2 tribes or nations; (2) reported social, behavioral, mental, and physical health outcomes; (3) completed driven by AIAN leaders, affiliated with the engaged communities (4) described work in the U.S.; (5) published written in the English language; and (6) published between January 1, 1970 to November 30, 2019. The focus of the review was on the link between health and intertribal collaborations, thus we excluded literature that focused on: (1) law; (2) environmental right influence; (3) international locations; (4) systematic reviews; (5) tribal epidemiology centers; (6) epidemiological reports; (7) community surveys results; and (8) research descriptions in which tribal members were human subjects. The data extracted were arranged as follows: (1) tribal communities involved; (2) year of publication; (3) with or without governmental influence; and (4) results.

Three Indigenous reviewers independently screened the titles and abstracts of the retrieved publications. Full articles were obtained and reviewed when inclusion and exclusion could not be ascertained from the abstracts alone. Data from each article were extracted by one reviewer and accuracy was assessed by a second reviewer. Any disagreements were settled by discussion and a third reviewer to achieve consensus. The data extracted were as follows: (1) title, year and authors; (2) types of collaboration, with an outside source or at a tribal, state, or national level; and (3) the use of an Indigenous framework.

Once the articles meeting the inclusion criteria were confirmed, each reviewer identified collaboration descriptors and themes. The three reviewers then shared their independently developed descriptors and themes to reach consensus on elements that demonstrated the unique characteristics and contributed to the strength of the collaborations.

Results

The combination of the search terms and indices yielded an initial identification of 27 publications. Twelve articles were judged eligible for full-text review and after further discussions, nine articles were excluded with reason. Reviewers applied the inclusion and exclusion criteria, intertribal definition, and focus on AIAN-driven to the remaining sixteen articles. Three articles met all criteria. See Figure 1 for the detailed flowchart of the articles’ inclusion and exclusion process.

Figure 1.

Flowchart describing the articles for inclusion in systematic review.

Articles excluded

Nine articles were excluded based on non-tribal researcher initiation, absence of tribal leadership, and/or tribal participation regulated to research subjects. Several of these articles were labeled as “intertribal collaboration” yet, the AIANs involved were not leaders within the communities, rather, were engaged individuals seen as the representative of that AIAN community. Lastly, several of the articles were extracted due to lack of tribal leadership direction or input. Reviewers agreed that these components undermined the knowledge and power held within intertribal collaboration efforts.

Articles included

The articles which met the inclusion criteria are described in Table 1. These include an essay from the American Indian Higher Education Consortium (AIHEC) (Billy & Goetz, 2016); a qualitative analysis of a round table discussion for traditional and Western health professionals (Moorehead et al. 2015); and a scientific article reporting on the design and outcomes of a substance use prevention program among California tribes (Moore et al. 2018).

Table 1.

Article Descriptions and Themes

	Billy & Goetz (2016)	Moorehead, Gone, & December (2015)	Moore et al. (2018)
Setting	National	Regional	Tribal
Tribal Participation	National	Regional	Regional
Tribally Initiated/Requested	x	x	x
Topic Area	Tribal colleges	Healthcare practices in mental health services	Underage drinking
Intervention Location on Tribal Lands	x	N/A	x
Collaboration Participants	American Indian Higher Education Consortium with Tribal Colleges/University leaders and State Senators.	18 traditional healers, clinically trained service providers and cross-cultural mental health researchers from Detroit, New Mexico, Montana, and First Nations University of Canada.	Clinical, research, & environmental scientific partners; 9 AIAN clinicians serving the 9 consortium Tribes of Southern California; local tribal members of medical & administrative leadership of the clinics; advisory panels of local tribal leaders.
Method of Collaboration	National network	1-time roundtable series	Nine-year research partnership
Policy Development at end of Collaboration	x	N/A	x
Indigenous Framework Used	x	x	x
Traditional Language Used in Intervention	x	x
Collaboration Strengths	National advocacy platform Policy development Federal policy recognition	Integration of healthcare Professional and traditional knowledge Facilitated discussions	Large sample size Active tribal leadership and support Multi-level intervention Sustainable design
Collaboration Barriers	Change in national leadership, administrations, and funding opportunities	No barriers were found	Inconsistent survey reach, unmeasured outreach impact
Recommendations for collaboration	Utilize bipartisan advocacy approach Honor treaties Honor federal trust relationship	Utilize cultural programming Utilize mutual and respectful conduct Maintain transparent and honest communication Recognize cultural differences in facing challenges	Presence of active tribal participation, advocacy, and asset utilization ensure successful implementation of intervention and outreach

Article Descriptions

Advancing Tribal Students and Sovereign Nations: AIHEC’s Vision for Tribal College Movement, Billy & Goetz (2016).

This article describes a collaboration at a national level with participation from all tribes located in the United States. Each tribe had requested the development of the consortium to support tribal colleges on reservations. With the assistance from national collaboration, the beginning consortium had grown over the years with the implementation of an AIAN framework. Strengths of this collaboration were the national advocacy platform, opportunities for policy development, and federal policy recognition. Barriers included changes in leadership, administration, and funding opportunities. Although the specific barriers identified are different across collaborations, their similarity lies in the absence of a clear implementation plan that identifies resources (financial and administrative) and achievable outcomes.

The Gathering of Native American Healers by Moorehead et al. (2015).

This article describes a retreat among Indigenous traditional healers, AIAN service providers, and non-AIAN mental health researchers to discuss the interface of Indigenous healing practices and mental health treatments in community-based services for AIANs. The collaboration allowed participants to discuss the importance of traditional healing and the characteristics needed for future partnerships. Strengths of this collaboration was the open dialogue between traditional healers, non-AIAN providers, and researchers promoting an exchange of ideas and perspectives. The collaboration and open dialogue also helped to highlight how historical trauma affects the mental health in the AIAN population. This collaboration brought together Indigenous and biomedical healing practices to address unique social determinants of health that affect these populations. No barriers were identified in this article.

The Prevention of Underage Drinking on California Indian Reservations Using Individual- and Community-Level Approaches, Moore et al. (2018).

This article describes an ongoing collaborative intervention implemented at a multi-tribal level with participation from 9 California Indian reservations. Leaders of the nine reservations requested the project to be conducted by the Pacific Institute for Research and Evaluation with the help from the Scripps Research Institute, to address the underage drinking epidemic. The intervention consisted of two individual-level approaches using motivational interviewing and psychoeducation, while the community-level approach focused on decreasing underage access to alcohol and reinforcing community norms against providing alcohol to youth. Strengths of this collaboration include the collaborative relationships between the project researchers and the California School Districts in the nearby reservations and Southern California Tribal Health Clinic. Other strengths included high participation among other tribes, tribal leadership support, multi-level intervention, and sustainable design. Barriers included inconsistent survey outreach and unmeasured impact. The analysis of the three articles which met the inclusion criteria, resulted in four themes: (1) capacity building, (2) integration of cultural values, (3) social mobilization, and (4) advocacy and awareness. Refer to Table 1 for a detailed description of the articles’ description and themes.

Overarching Themes

Capacity Building

The World Health Organization (2019) describes capacity building as the development of knowledge, skills, commitment, structures, systems, and leadership to enable effective health promotion. Two articles, Moorehead et al. (2015) and Moore et al. (2018), discussed opportunity for training and knowledge to be passed from AIAN distinct leaders to researchers, to address research on health disparities. Billy & Goetz (2016) describes capacity building through providing opportunity for members of the AIHEC to share their stories with distinct US government leaders to garner support for continued education funding.

Social Mobilization

The World Health Organization (2019) states that social mobilization brings together personnel and/or community members to raise awareness on a common issue (World Health Organization, 2019). Interdisciplinary approaches were used to engage professionals outside the realm of knowledgeable tribal leaders to create a force that could drive policy development or change within the community. Each method of collaboration was community focused and drew in community members to participate in the process to improve their communities. There were few references to social mobilization in the 3 articles, but respect is a highly valued social behavior and supports the engagement of many community voices (Hart 2010). Project efforts would not be achieved without the assistance of all parties present, such as community members, grassroots leaders, tribal leaders, and national representatives.

Cultural Values

Cultural values were a recurring theme. The participants and advocates for AIAN communities demonstrated resilience and perseverance throughout their articles. The articles supplemented the importance of “cultural values” through emphasizing locally based and culturally sensitive approaches that acknowledge the various barriers and motivators for AIAN communities. Furthermore, shared history and values that helped develop holistic institutions for AIAN communities contributed to exercising sovereignty. In other words, the AIAN communities could strengthen their sovereignty by sustaining their Indigenous practices and passing down beliefs and values to future generations. Cultural values are an essential component for AIAN communities and require further investigation, especially with relations to public health practices and intertribal collaboration.

Advocacy and Awareness

Increased tribal understanding and acknowledgment of social inequalities, disparities in funding, and lack of culturally tailored programs spurred tribes to use local, regional, and national platforms to advocate for needed assistance and interventions. The articles described factors needed to ensure the sustainability of programs, which included: (1) local relevance and potential tribal benefits; (2) leadership support and contributions; (3) policy development; and (4) local mobilization. The articles also described a proactive approach, which valued strategic planning, cultural sensitivity, and responsiveness to tribal needs and requests to modify environment, policy, and regulations.

The California Indian Consortium (CIC) and the AIHEC leadership (Moore et al. 2018; Billy & Goetz, 2016) exemplified a strategic planning approach (Jorgenson, 2007) to achieve its vision and goals with a critical awareness of the conditions, constraints, and assets of their programs. For the CIC, the tribes’ social health was negatively impacted by underage alcohol use facilitated by illegal local alcohol sales; however, the tribes’ ability to request a collaborative partnership with local healthcare services and prevention scientists aided in addressing underage drinking. Through the partnership, individual-, community-, and environmental-level interventions were created, informed by cultural teachings and reinforced by tribal support and regulation. For example, alcohol sale outlets were monitored and tested to determine the prevalence of illegal underage-alcohol sales and frequency of clerk identification checks. Implementing this intervention was supported by a Tribal Declaration of Support and consistent store tests. This intervention contributed to increased compliance and decreased alcohol sales to underaged consumers (Moore et al. 2018).

Discussion

Exploring the peer-review literature for evidence of intertribal collaboration highlighted the dearth of AIAN-initiated programs. The literature suggests that the lack of intertribal collaborations may be an outcome of several factors, including insufficient funding, distance between tribal communities dictated centuries ago by reservation designations, differences in tribal health priorities, diverse cultural values, and distinct tribal institutional protocols. The systematic review resulted in few peer-reviewed articles yet, highlights a research gap in AIAN health management and collaboration. It can be assumed that intertribal collaborations are underreported in the peer-review literature; however, the paucity points to the overall scarcity of AIAN-driven health research beyond process or formative articles. Considering tribes have similar socioeconomic status, health issues, and health solutions, contributions to the literature could guide the establishment of tribal-collaboration frameworks or approaches across populations. Authors would like to acknowledge the diverse and rich differences between tribal nations, and the similarities in history and current experiences.

Limitations

Tribal collaborations are often documented in tribal policy or legislative agreements, that are circulated internally or through tribally controlled outlets. A limitation is that these collaborations are not documented in the peer-reviewed literature. Moreover, barriers evident in the search process was the use of the term “American Indian/Alaska Native” which is familiarized with AIAN population’s sole contribution to collaboration as research subjects but not the creator or collaborator of health programs. This non-AIAN driven effort did surface in the initial stages of the search. The term AIAN also generalizes tribes, thus, the number and identities of tribes, tribal needs or health priorities, and leadership directives of tribes involved in certain programs or initiatives is not properly counted.

Recommendations

Recommendations for future research includes promotion of intertribal collaboration to address regional health disparities to improve sustainability of health research, intervention, and advocacy that advances tribal well-being. Additional systematic research needs to investigate grey literature such as reports and publications from tribal government and departments, foundations, and national committees to better understand the frequency, context, and process under which collaboration is conducted.

Conclusion

True intertribal collaborations involve multiple tribes interacting with one another to attain beneficial outcomes for tribal citizens. Utilizing an intertribal collaboration approach creates a unified coalition that yields a large collective voice to advocate for tribal needs and leverages cultural assets to address challenges. Intertribal collaboration promotes social cohesion and has contemporary precedent and historical beginnings in tribal society. This systematic literature review revealed that programs and projects labeled “intertribal” did not necessary involve AIAN driven interaction between tribes. This practice should be discouraged, as it is misleading and may not reflect AIAN voices, opinions, and approaches. AIAN and non-AIAN health researchers are encouraged to explore the grey literature in the form of tribal policies, tribal department reports, and non-academic tribal institutions to understand the extent to which intertribal collaborations have been used to address the health of tribal citizens, and thus, the promise of a well-executed intertribal collaboration.