A review of protective factors and causal mechanisms that enhance the mental health of Indigenous Circumpolar youth

Figures & data

Fig. 1.  Medical Subject Headings (MeSH) used for database search in MedLine.

Fig. 2.  Search equation used in PubMed and Web of Knowledge based on MeSH, test searches, and consultation with research librarian.

Table I. Table of inclusion and exclusion criteria used in determining which articles were applicable to review

Inclusion criteria	Exclusion criteria
English-language source	Non-English-language source
Peer-reviewed journal articles (empirical or theoretical)	Books, reviews, editorials, conference proceedings,  commentaries
Anything published up until 25 September 2013	N/A
Focus on (or distinction of) an Indigenous population (i.e. Inuit, Yup'ik, Inupiat, Sami)	Population included in study is not Indigenous or there is no  distinction between Indigenous and non-Indigenous populations
Include youth as only population of study or as a distinct group in study participants with specific discussion/coverage on youth	Youth are not included in study or are only briefly mentioned
Include at least 1 paragraph on resilience/protective factors that enhance mental health or make explicit reference to certain protective factors	Only focus on risk factors and no mention of resilience/protective factors
Circumpolar regions/countries only (Canada, Greenland, Norway, Russia, Finland, Iceland, Sweden or Alaska, USA)	Non-Circumpolar countries
N/A	Duplicate of previously found article

Table II. Categories of information extracted from articles including general aspects and specific questions

Data extraction categories	Questions asked
Article information	First author
	Year
	Journal
Geographic	Study site – community, state/territory/province, country
	Objectives
	Methodology/study design
	Measures used
	Other methods notes
	Timeframe of study
Study population	Indigenous group (Yu'pik, Sami, Inuit)
	Size of study population
	Age
	Gender considered
Protective factors and causal mechanisms	What are the protective factors identified?
	Why? Pathways through which these factors protect/increase resiliency
	Mental health behaviours discussed (outcomes to avoid)
	Key results
Wording	Explicitly stated that these are protective factors? (wording)
	Is the word “resilience” used in the article?
Recommendations and take home messages	Recommendations
	Intervention/prevention thoughts?
	Strategies, interventions, or best practices within communities that promote strong mental health in the younger generation?
	Are the recommendations based on protective factors?
	Lessons that can be applied to future Indigenous youth-related mental health research and work?
Other	Other notes
	Introductory material useful to setting the stage
	Weaknesses – what was not included?

Table III. Breakdown of articles excluded in title and abstract screening

Inclusion criteria not met	Number of articles
Not youth	6
Not Indigenous	3
Not Arctic	35
Not youth or Indigenous	1
Not Arctic or Indigenous	6
Not youth or Arctic	9
Not youth, Indigenous, or Arctic	5
Not mental health	4
Not protective factors	4
Not Indigenous or mental health	1
Not at all related	14
Not Arctic, youth, mental health	8
Not Indigenous, youth, mental health	3
Not Arctic or mental health	7
Not youth or mental health	1
Not Arctic, Indigenous, or mental health	1

Fig. 3.  Search strategy and results.

Table IV. List of final 15 articles included in literature review with the Indigenous group studied and the location of research

Articles reviewed	Indigenous group	Location
Allen, J., G. V. Mohatt, et al. (2006). “The Tools to Understand.” Journal of Prevention & Intervention in the Community 32(1–2): 41–59.	Alaska Natives	Alaska (USA)
Bals, M., A. L. Turi, et al. (2010). “Internalization symptoms, perceived discrimination, and ethnic identity in indigenous Sami and non-Sami youth in Arctic Norway.” Ethnicity & Health 15(2): 165–179.	Sami	Northern Norway (Finnmark, Troms, Nordland)
Bals, M., A. L. Turi, et al. (2011). “The relationship between internalizing and externalizing symptoms and cultural resilience factors in Indigenous Sami youth from Arctic Norway.” Int J Circumpolar Health 70(1): 37–45.
Bals, M., A. L. Turi, et al. (2011). “Self-reported internalization symptoms and family factors in indigenous Sami and non-Sami adolescents in North Norway.” Journal of Adolescence 34(4): 759–766.
Decou, C.R., M.C. Skewes, et al. (2013). “Traditional living and cultural ways as protective factors against suicide: perceptions of Alaska Native university students.” Int J Circumpolar Health 72:20968.	Alaska Natives	Alaska (USA)
Ford, T., S. Rasmus, et al. (2012). “Being useful: achieving indigenous youth involvement in a community-based participatory research project in Alaska.” Int J Circumpolar Health 71(0): 1–7.	Alaska Natives	Southwest Alaska (USA)
Kirmayer, L. J., M. Malus, et al. (1996). “Suicide attempts among Inuit youth: A community survey of prevalence and risk factors.” Acta Psychiatrica Scandinavica 94(1): 8–17.	Inuit	Nunavik, Northern Quebec (Canada)
Kirmayer, L. J., L. J. Boothroyd, et al. (1998). “Attempted suicide among Inuit youth: Psychosocial correlates and implications for prevention.” Canadian Journal of Psychiatry-Revue Canadienne De Psychiatrie 43(8): 816–822.
Kral, M. J., L. Idlout, et al. (2011). “Unikkaartuit: meanings of well-being, unhappiness, health, and community change among Inuit in Nunavut, Canada.” Am J Community Psychol 48(3–4): 426–438.	Inuit	Igloolik and Qikiqtarjuaq, Nunavut (Canada)
Mohatt, G., S. M. Rasmus, et al. (2004). “‘Tied together like a woven hat:’ Protective pathways to Alaska native sobriety.” Harm Reduction Journal 1(1): 10.	Alaska Natives	Alaska (USA)
Spein, A.R., C.P. Pedersen, et al. (2013). “Self-rated health among Greenlandic Inuit and Norwegian Sami adolescents: associated risk and protective correlates.” Int J Circumpolar Health 72:19793.	Inuit and Sami	Greenland and North-Norway
Wexler, L. and B. Goodwin (2006). “Youth and adult community member beliefs about Inupiat youth suicide and its prevention.” Int J Circumpolar Health 65(5): 448–458.	Inupiat	Alaska (USA)
Wexler, L., K. Jernigan, et al. (2013). “Lived Challenges and Getting Through Them: Alaska Native Youth Narratives as a Way to Understand Resilience.” Health Promotion Practice DOI: 10.1177/1524839913475801.
Wexler, L. (2013). “Looking across 3 generations of Alaska Natives to explore how culture fosters indigenous resilience.” Transcultural Psychiatry DOI: 10.1177/1363461513497417.
Wexler, L., L. Joule, et al. (2013). “‘Being responsible, respectful, trying to keep the tradition alive:’ Cultural resilience and growing up in an Alaska Native community.” Transcultural Psychiatry DOI: 10.1177/1363461513495085.

Table V. Community-level protective factors identified in literature review

Protective factors	Authors who identified the protective factor
Positive role models	Allen et al., 2006	Mohatt et al., 2004
Wexler and Goodwin, 2006	Wexler, Joule, et al., 2013
Sense of collective responsibility and	Allen et al., 2006	Ford et al., 2012
community connectedness	Mohatt et al., 2004	Wexler, 2013
Wexler, Jernigan, et al., 2013
Sense of belonging in community	Wexler, 2013
Meaningful opportunities to be involved within	Allen et al., 2006	Ford et al., 2012
community or school community	Mohatt et al., 2004	Decou et al., 2013
Community-wide limits/standards/expectations	Allen et al., 2006	Mohatt et al., 2004
Safe places	Allen et al., 2006	Mohatt et al., 2004
Supportive, caring, encouraging, cohesive communities	Mohatt et al., 2004	Wexler and Goodwin, 2006
that show concern and reach out to youth	Decou et al., 2013	Wexler, Jernigan, et al., 2013
Strong relationships with community members	Kirmayer et al., 1998	Wexler and Goodwin, 2006
(peers or other adults)	Decou et al., 2013	Wexler, Jernigan, et al., 2013
Wexler, Joule, et al., 2013
Mentorship from older generations	Wexler, Jernigan, et al., 2013	Wexler, Joule, et al., 2013
Continuous communication, talking, and interaction	Kral et al., 2011	Wexler and Goodwin, 2006
Regular church attendance	Kirmayer et al., 1996	Kirmayer et al., 1998
Community control	Kral et al., 2011
Cultural revitalization	Bals et al., 2010
Community recognition, respect, and appreciation	Wexler, Jernigan, et al., 2013

Table VI. Family-level protective factors identified in literature review

Protective factors	Authors who identified the protective factor
Close relationship with parents	Allen et al., 2006
Mohatt et al., 2004
Spein et al., 2013
Affection and praise	Allen et al., 2006
Mohatt et al., 2004
Wexler, Jernigan, et al., 2013
Models of sobriety and safe/protective family environment	Allen et al., 2006
Mohatt et al., 2004
Transmission of expectations and values	Allen et al., 2006
Mohatt et al., 2004
Family history of having received treatment for psychiatric problem	Kirmayer et al., 1996
Parental approval of friends	Bals et al., 2011b
Sense of being treated as special/being valued	Allen et al., 2006
Mohatt et al., 2004
Kinship structure (i.e. family connectedness and importance of	Bals et al., 2010
extended family and adopted kin)	Bals et al., 2011b
Kral et al., 2011
Mohatt et al., 2004
Wexler, Jernigan, et al., 2013
Wexler, Joule, et al., 2013
Native language learned at home and competence in native language	Bals et al., 2010
Bals et al., 2011b
Ethnic socialization at home	Bals et al., 2010
Bals et al., 2011b

Table VII. Individual-level protective factors identified in literature review

Protective factors	Authors who identified the protective factor
Belief in self	Allen et al., 2006	Bals et al., 2010
Mohatt et al., 2004
Sense of purpose	Wexler, 2013
Physically being in home community	Wexler, 2013
Wanting to contribute, be useful to others, take care of others,	Allen et al., 2006	Ford et al., 2012
and give back to the community (i.e. to be a role model)	Mohatt et al., 2004	Wexler, Joule, et al., 2013
Wexler, Jernigan, et al., 2013
Mindfulness and awareness of the consequences of one's individual actions upon the community	Allen et al., 2006	Mohatt et al., 2004
Reflection	Mohatt et al., 2004
Sense of responsibility to oneself, family, and/or community	Allen et al., 2006	Mohatt et al., 2004
Wexler, Jernigan, et al., 2013	Wexler, Joule, et al., 2013
Learning values of harmony and co-operationas well as autonomy and hardiness	Bals et al., 2011a
High level of academic achievement	Kirmayer et al., 1996	Spein et al., 2013
Ethnic pride	Bals et al., 2011a	Ford et al., 2012
Wexler, Jernigan, et al., 2013
Cultural/ethnic identity and/or affiliation	Wexler, 2013	Wexler, Joule, et al., 2013
Traditional knowledge, cultural values, and practice	Bals et al., 2010	Bals et al., 2011a
(e.g. eating country foods, being out on the land,	Kirmayer et al., 1998	Kral et al., 2011
doing subsistence activities, attending tribal events,	Decou et al., 2013	Wexler, Jernigan, et al., 2013
listening to traditional stories)	Wexler, Joule, et al., 2013	Wexler, 2013
Systems of reciprocity and reciprocal bonds	Wexler, Jernigan, et al., 2013	Wexler, Joule, et al., 2013
Physical activity and active lifestyle	Spein et al., 2013	Decou et al., 2013
Staying busy	Wexler, Jernigan, et al., 2013
Self-reliance (e.g. seeking support from a friend, keeping a journal, creatively handling problems)	Wexler, Jernigan, et al., 2013	Wexler, Joule, et al., 2013
Being committed to community and culture	Wexler, 2013

Table VIII. Causal pathways identified for protective factors around one's social environment including family, peer, and community relationships

Protective factor	Causal pathway	First author
Kinship	Extended family can provide support in the event that the immediate family cannot, sense of connection to others beyond the immediate family.	Bals (2010, 2011b)
Spending time with family and kin allows for opportunities to learn culture.	Kral (2011)
Close relationship with peers	Allows opportunity for youth to take on adult-like roles and offer support, be dependable, responsible, and responsive to others. Provides a chance to develop awareness of others and to also receive support from peers.	Wexler, Jernigan (2013) Wexler, Joule (2013)
Social Network (Includes relationships with family, peers, and community members)	Relationships and friendships can mediate access to cultural and material assets and thus increase one's capacity (e.g. kin, adopted kin, or friends can provide support resources like a skidoo available to get out on land). These relationships also provide a platform for youth to build/construct their identity and resilience.	Wexler, Jernigan (2013) Wexler, Joule (2013)
Mentorship from older generations	Source of support and guidance in how to handle problems. Provides examples to youth of how to get through difficulties while instilling belief in youth that they can also get through difficulties like their mentors and ancestors.	Wexler, Jernigan (2013)

Table IX. Causal pathways identified for various protective factors

Protective factor	Causal pathway	First author
Regular church attendance	Participation in a community activity, engage in community and family networks, strengthens social ties, and builds strong social support. Also may offer consolation and hope in difficult times.	Kirmayer (1998)
High academic achievement	Source of self-esteem, builds problem-solving skills, presents hope for future.	Kirmayer (1996)
Awareness, mindfulness, and reciprocity of action	A mechanism in and of itself – individuals who are socialized in this context are more sensitive to the effects of their behaviours on the whole, and draw strength from the whole.	Mohatt (2004)
Sense of being treated as special/important	Encourages youth to live up to high standards and be responsible for themselves and others.	Mohatt (2004)
Opportunities (in the community, at school, with research project)	Opportunities to be involved with research as co-researchers engages and empowers youth, giving them sense of control and ownership. Praise from adults and elders gives youth pride. Research process offers space to talk to peers, reflect on mental health problems, and learn about oneself. Youth-researcher partnerships also increase egalitarian relations between young people and adults.	Ford (2012)
Some activities, such as sport teams, provide incentive to do well in school (e.g. must do well in classes to participate in sport team).	Wexler, Jernigan (2013)
Self-reflection	Often leads to a conscious decision (i.e. to not drink or to drink responsibly)	Allen (2006)
Being responsible	Through activities like fixing something, doing homework, watching siblings, raising money for community, or doing chores, youth have a chance to contribute in a meaningful way and gain a sense of purpose and personal well-being. Also demonstrates autonomy and community connectedness.	Wexler, Jernigan (2013)
Being useful	Leads to feeling responsible and creates systems of reciprocity and availability to help one another which leads to young people having someone to talk to in difficult times such as times of loss. Reflects Indigenous values.	Wexler, Jernigan (2013)
Physical activity	Positively influences self image, family, and peer relationships, and general well-being among youth.	Spein (2013)
Sense of belonging in home community	Through a sense of belonging in one's home community youth feel more connected to their culture.	Wexler (2013)

Note that not all protective factors were linked to a causal pathway.

Table X. Causal pathways identified for protective factors around culture including practicing traditional activities and having a positive ethnic identity

Protective factor	Causal pathway	First Author
Learning and practicing culture (e.g. traditional practices and subsistence activities)	Strengthens self-esteem, ethnic identity, and self-regulation skills. Sharing cultural knowledge enhances in-group cohesiveness and support through experience of shared meaning-making. Also provides an opportunity to participate in the passing down of traditional knowledge and cultural values thus creating feeling of keeping culture alive. Enhances relationships between youth and the land and between youth and their families. Facilitates and creates context for important mentoring relationships and connection to older generations leading to youth feeling supported. Promotes healthy living, facilitates involvement and creates opportunities for sharing. Gain new skills (e.g. hunting, camping, riding) and knowledge. Develops sense of ethnic pride. Provides a meaningful way for youth to contribute and give back to the community, earn respect for skills, and feel appreciation from community (e.g. through sharing kill). Subsistence skills demonstrate strength and survival and are associated with ability to respond and to be resilient in face of hardship. Being out on the land requires youth to act selflessly, be responsible and less petty, show respect, rely on others, and distinguish between what is essential vs. trivial. Meaningful engagement in traditional activities also contributes to sense of purpose, feeling more self efficacious, and staying busy. Traditional activities associated with fulfilment, sense of calm, and sense of being special. Shows cultural continuity with one's heritage and connects youth to sense of how life used to be. Provides time with parents to learn skills and how to be in the world. Ability to practice culture is source of pride and well-being.	Bals (2010, 2011a) Decou (2013) Wexler, Jernigan (2013) Wexler, Joule (2013) Kral (2011)
Positive cultural/ethnic identity and shared heritage	Leads to and increases self-esteem, feelings of self-worth, self-efficacy, connectedness, commitment, and purpose. Provides sense of belonging. Offers perspectives to draw from to overcome challenges and be well. Evokes sense of strength and capability. Creates larger shared context in which youth can situate themselves and their struggles in relation to others, to their history, and to a collective. Provides a means to structure one's understanding and ideas of their role in the world (e.g. as a youth, as Inuit/Sami/Inupiat)	Wexler (2013) Wexler, Joule (2013) Allen (2006)
Ethnic socialization	Influence on interpersonal and intra-psychic processes, increases self-confidence, develops positive attitudes towards ethnic identity, teaches self-regulation and coping skills.	Bals (2010, 2011b)
Native language	Personal and relational significance – important part of ethnic identity that strengthens in-group cohesion, personal pride, and sense of history and culture.	Bals (2010, 2011b)