Background
Indigenous scholars agree that although Indigenous civilizations are richly diverse, they have also shared common values and beliefs that facilitated healing, positive meanings, and confidence in the future [
1]. Ceremonial methods for coping with stress in times of adversity enabled Indigenous peoples to process loss and grief [
2]. Healing traditions were passed down intergenerationally as parents and Elders used story-telling and experiential learning to teach young people how to exercise resilience, or, find mental, physical, emotional, and spiritual wellbeing when they experienced difficulty [
3]. Many Indigenous cultural practices, languages, and spiritual beliefs have survived despite 500 years of colonization in Canada. This reinforces the imperative to find alternatives to risk models of disease to identify sources of strength or resilience that may protect the health of young Indigenous people in Canada.
Colonization in Canada has included forced removal from traditional lands, genocide, and legislative measures to suppress Indigenous cultures, ceremonies, and economic development [
4]. The
Gradual Civilization Act of 1857 was one of the most damaging pieces of legislation as it initiated the church-state partnership that established the Indian Residential School System. Between 1874 and 1996, over 150,000 Indigenous children were forcibly removed and placed in residential schools. The system alienated children from their cultures, languages, and communities in an effort to Christianize and assimilate them into Canadian society [
4]. Using corporal and degrading punishments, missionary teachers taught children to be ashamed of their Indigenous identity. It is estimated that more than 70 % of children in residential schools were routinely abused physically, sexually, or emotionally, in addition to being deprived of emotional or physical nurturing [
4]. When former students returned to their home communities, many faced feelings of alienation resulting from having lost their connection to culture [
3]. Further, residential schools severely disrupted traditional models of child rearing, and many former students unintentionally replicated the traumas they had experienced within their families and communities. Combined, these experiences prompted a cyclical effect of intergenerational trauma.
Intergenerational trauma is considered one of the most disastrous legacies of colonization and the residential school system [
5]. The ongoing effects are evident within Indigenous communities that are struggling with interrelated crises of family violence, poverty, addictions, lack of traditional skills, lack of role models, and feelings of isolation. Moreover, Indigenous activists and scholars have maintained that provincial child welfare systems in Canada have perpetuated intergenerational trauma and fragmentation of Indigenous families [
6]. Indigenous parents routinely face discrimination and racism within the child welfare system, and federal funding incentivizes long-term separations of Indigenous children from their families, communities, and cultures [
7]. Consequently, though only 7 % of children in Canada have Indigenous ethnicity they comprise 48 % of children in the foster care system [
8].
Research suggests that young Indigenous people living with unaddressed historical and lifetime traumas are more likely to use illicit drugs as a coping mechanism [
9]. Further, young urban Indigenous people who use drugs in Canada experience high levels of injection drug use [
10], residential transience [
11], high risk sex [
12], sex work [
13], and sexual violence [
14]. These cumulative traumas have also manifest as increased HIV and hepatitis C (HCV) vulnerability [
15‐
19]. For example, extant literature has demonstrated that young Indigenous people who use drugs and have experienced childhood sexual abuse are twice as likely to be living with HIV infection [
9], and those who had at least one parent who attended residential school are twice as likely to be living with HCV infection [
20]. Taken together, these vulnerabilities have contributed substantially to the overrepresentation of Indigenous people among those living with HIV and HCV infection in Canada. Recent 2011 data indicates that Indigenous people constituted an estimated 12.2 % of all people in Canada newly diagnosed with HIV, which corresponded to an HIV incidence rate that was 3.5 times higher than among non-Indigenous people [
21]. Likewise, between 2002 and 2008, the estimated incidence of HCV infection was 4.7 fold higher among Indigenous people than non-Indigenous people [
19].
In this context of heightened vulnerability, Indigenous leaders have called for recognition of resilience among their young people, including acknowledging strengths-based factors that may be protective against HIV and HCV infection [
22]. The most widely accepted definition of resilience in health sciences is
positive adaptation despite adversity [
23]. Resilience researchers have sought to look beyond deficit models of health to identify strength-based resources that promote wellness.
However, measures used to assess resilience are often limited because they are based on individualistic outcomes specifically valued by non-Indigenous cultures, such as self-sufficiency and self-esteem, and narrow definitions of healthy functioning, including staying in school and abstaining from substance use [
24]. Moreover, resilience research has frequently failed to consider complex historical and cultural contexts when measuring resilience among marginalized youth and those outside of the dominant culture [
25]. It follows that any consideration of resilience among young Indigenous people in Canada must acknowledge the historical and present-day injustices that impede resilience as well as the culturally-specific community strengths that support resilience [
26].
A small but growing body of research in Canada has moved beyond individualistic, linear, and western notions of resilience to identify ways in which culture, language, and spirituality buffer adversity and create “cultural resilience” among Indigenous peoples [
27]. Chandler and Lalonde’s [
28] study involving 196 Indigenous bands in British Columbia (BC), demonstrated that factors associated with ‘cultural continuity’ − including self-governance, band-controlled health and education initiatives, and speaking traditional languages − were associated with lower rates of suicide among Indigenous youth. Very few studies have explored the roles that culture and resilience play in the health of young, urban Indigenous people. One study involving Indigenous young people in Winnipeg, Canada, found that those who believed it was important to participate in traditional cultural activities scored higher on an emotional competence scale and were less likely to use alcohol or be involved in crimes [
29]. Further identifying sources of resilience may therefore be especially important for understanding and responding to HIV and HCV vulnerability among young urban Indigenous people who use drugs and who may be disconnected from their home communities, languages, cultures, and spirituality [
27].
To our knowledge no previous epidemiological studies have explored resilience among young, urban Indigenous people who use drugs and experience vulnerability to HIV and HCV exposure within high risk environments. This study sought to investigate the relationship between resilience and a range of positive and negative factors, including cultural connectedness, help-seeking, historical and lifetime trauma, drug- and sex-related risk, and psychological distress, among young Indigenous people who use drugs in British Columbia (BC), Canada.
Results
Descriptive statistics of demographic variables, historical trauma, childhood maltreatment, and resilience scores are displayed in Table
1. In 2011, participants’ mean age was 28.9 years (SD: 5.1); 51 % (n = 97) were women. Fifty-three percent were based in Prince George, 39 % in Vancouver, and 8 % in Chase. Nearly half (48 %) of participants had at least one parent who had attended residential school, and most (71 %) had been in foster care.
Table 1
Baseline comparisons of mean resilience scores by demographic and historical trauma variables and childhood maltreatment experiences among Cedar Project participants (n = 191)
All participants | 191 | 100 % | 62.04 | 22.22 | - |
Demographic and historical trauma variables | | | | | |
Age (mean, SD) | 28.89 | 5.07 | - | - | - |
Sex | | | | | |
Male | 94 | 49 % | 64.12 | 22.37 | 0.871 |
Female | 97 | 51 % | 60.72 | 23.65 |
Location | | | | | |
Prince George | 102 | 53 % | 60.13 | 25.22 | 0.248 |
Chase | 15 | 8 % | 68.93 | 13.53 |
Vancouver | 74 | 39 % | 63.75 | 21.71 |
Any parent attended residential school | | | | | |
No | 41 | 22 % | 63.97 | 21.45 | 0.629 |
Unsure | 57 | 30 % | 61.12 | 23.27 |
At least one parent attended | 92 | 48 % | 62.65 | 23.97 |
Ever in Foster Care | | | | | |
No | 56 | 29 % | 68.35 | 19.15 | 0.044 |
Yes | 135 | 71 % | 59.99 | 24.07 |
Education | | | | | |
Less than high school | 158 | 84 % | 61.55 | 22.73 | 0.037 |
High school or higher | 31 | 16 % | 67.83 | 19.21 |
Relationship status | | | | | |
Single | 19 | 10 % | 64.06 | 15.01 | 0.798 |
In a relationship | 169 | 90 % | 62.22 | 23.83 |
Childhood maltreatment severity | | | | | |
Emotional abuse | | | | | |
None | 57 | 31 % | 64.13 | 24.27 | 0.503 |
Low/Moderate | 68 | 37 % | 64.70 | 19.90 |
Severe | 61 | 33 % | 58.06 | 25.02 |
Physical abuse | | | | | |
None | 81 | 44 % | 63.65 | 23.34 | 0.894 |
Low/Moderate | 28 | 15 % | 63.80 | 22.15 |
Severe | 77 | 41 % | 60.52 | 23.26 |
Sexual abuse | | | | | |
None | 80 | 43 % | 62.36 | 24.67 | 0.996 |
Low/Moderate | 33 | 18 % | 62.57 | 24.67 |
Severe | 72 | 39 % | 62.40 | 22.89 |
Emotional neglect | | | | | |
None | 53 | 29 % | 69.94 | 20.49 | 0.005 |
Low/Moderate | 95 | 52 % | 60.74 | 23.21 |
Severe | 36 | 20 % | 53.08 | 23.41 |
Physical neglect | | | | | |
None | 39 | 21 % | 67.47 | 19.11 | 0.580 |
Low/Moderate | 73 | 40 % | 62.38 | 23.84 |
Severe | 72 | 39 % | 59.53 | 24.00 |
Sixty-nine percent of participants reported having been emotionally abused; among whom, 33 % reported severe abuse. Fifty-six percent had been physically abused, among whom 41 % reported severe abuse. Fifty-seven percent had been sexually abused, among whom 39 % reported severe abuse. Seventy-two percent had been emotionally neglected, among whom 20 % reported severe neglect. Finally, 79 % had been physically neglected, among whom 39 % reported severe neglect.
Reliability assessments suggested that Cedar Project data had very good fit to the hypothesized model (α = 0.961). The mean resilience score was 62.04 (SD: 22.2) for all participants with no significant difference between men and women. On average, greater resilience scores were observed among participants who had never been in foster care (p = 0.044) and those who had graduated from high school (p = 0.037). Differences in mean resilience for childhood maltreatment were found only for emotional neglect, with participants reporting low/moderate or severe neglect having lower mean resilience scores than participants who reported no emotional neglect (p = 0.005).
Protective factors associated with resilience
Table
2 presents results of LME models for all participants. Adjusted results are presented here. Examining the impact of time-invariant cultural factors, having a family who had often or always lived by traditional culture was associated with higher mean resilience scores (B = 7.70,
p = 0.004). Having a family who had often or always spoken traditional languages at home was also associated with higher resilience (B = 10.52,
p < 0.001).
Table 2
Unadjusted and adjusted LME models predicting the effects of study variables on mean resilience scores among Cedar Project participants (n = 191)
Potential Confounders | | | | | | | | | | |
Age | 0.29 | 0.27 | 1.05 | −0.25, 0.83 | 0.293 | | | | | |
Female sex | −2.59 | 2.77 | −0.93 | 8.02, 2.85 | 0.353 | | | | | |
Ever in Foster Care | −2.24 | 3.04 | −0.74 | −8.2-, 3.73 | 0.463 | | | | | |
Parents attended residential school | | | | | | | | | | |
No | - | | | | | | | | | |
Unsure | −4.44 | 3.86 | −1.15 | −12.02, 3.13 | 0.251 | | | | | |
At least one parent | 1.39 | 3.60 | 0.39 | −5.66, 8.44 | 0.700 | | | | | |
Location | | | | | | | | | | |
Prince George | - | | | | | | | | | |
Chase | 6.03 | 5.32 | 1.13 | −4.41, 16.46 | 0.260 | | | | | |
Vancouver | −2.81 | 2.93 | −0.96 | −8.55, 2.92 | 0.338 | | | | | |
High school education or higher | 7.25 | 3.73 | 1.94 | −0.06, 14.55 | 0.053 | | | | | |
In a relationship | −7.00 | 4.27 | −1.64 | −15.37, 1.36 | 0.102 | | | | | |
Childhood maltreatment severity | |
Emotional abuse | | | | | | | | | | |
None | - | | | | | - | | | | |
Low/Moderate | 2.86 | 3.53 | 0.81 | −4.05, 9.77 | 0.419 | - | - | - | - | - |
Severe | 1.93 | 3.57 | 0.54 | −5.07, 8.93 | 0.590 | - | - | - | - | - |
Physical abuse | | | | | | | | | | |
None | - | | | | | - | | | | |
Low/Moderate | 5.60 | 3.77 | 1.48 | −1.80, 12.99 | 0.140 | - | - | - | - | - |
Severe | 2.06 | 3.13 | 0.66 | −4.08, 8.19 | 0.513 | - | - | - | - | - |
Sexual abuse | | | | | | | | | | |
None | - | | | | | - | | | | |
Low/Moderate | −1.01 | 3.90 | −0.26 | −8.74, 6.53 | 0.796 | - | - | - | - | - |
Severe | 2.59 | 3.07 | 0.84 | −3.43, 8.61 | 0.400 | - | - | - | - | - |
Emotional neglecta | | | | | | | | | | |
None | - | | | | | - | | | | |
Low/Moderate | −5.44 | 3.19 | −1.70 | −11.69, 0.82 | 0.090 | −5.48 | 3.19 | −1.72 | −11.73, 0.78 | 0.088 |
Severe | −12.96 | 4.01 | −3.23 | −20.83, −5.09 | 0.001 | −13.34 | 4.04 | −3.30 | −21.25, −5.42 | 0.001 |
Physical neglect | | | | | | | | | | |
None | - | | | | | - | | | | |
Low/Moderate | 1.35 | 3.85 | 0.35 | −6.20, 8.90 | 0.727 | - | - | - | - | - |
Severe | −1.38 | 3.864 | −0.357 | −8.95, 6.20 | 0.721 | - | - | - | - | - |
Cultural connectedness |
Family often/always lived by traditional cultureb | 7.96 | 2.55 | 3.13 | 2.97, 12.95 | 0.002 | 7.70 | 2.64 | 2.92 | 2.53, 12.87 | 0.004 |
Traditional language often/always spoken at homec | 10.66 | 2.41 | 4.43 | 5.94, 15.38 | <0.001 | 10.52 | 2.45 | 4.29 | 5.72, 15.33 | <0.001 |
Know how to speak traditional languaged | | | | | | | | | | |
No | - | | | | | - | | | | |
A little bit | 1.70 | 2.45 | 0.69 | −3.09, 6.49 | 0.25 | 2.28 | 2.46 | 0.93 | −2.55, 2.71 | 0.178 |
Yes | 13.37 | 4.19 | 3.19 | 5.15, 21.58 | 0.001 | 13.06 | 4.19 | 3.12 | 4.85, 21.27 | 0.001 |
Often/always lived by traditional culture in past six monthse | 7.15 | 2.76 | 2.59 | 1.74, 12.55 | 0.010 | 6.50 | 2.88 | 2.26 | 0.86, 12.14 | 0.025 |
Participated in traditional ceremoniesf | 3.44 | 2.04 | 1.68 | −0.56, 7.45 | 0.095 | 2.68 | 2.08 | 1.29 | −1.40, 6.76 | 0.199 |
Other protective factors in the past six months |
Accessed drug/alcohol treatmentg | 3.48 | 2.22 | 1.57 | −0.87, 7.82 | 0.118 | 4.84 | 2.29 | 2.11 | 0.35, 9.34 | 0.036 |
Accessed any counsellingh | 3.86 | 2.38 | 1.62 | −0.80, 8.52 | 0.105 | 4.21 | 2.38 | 1.77 | −0.46, 8.89 | 0.079 |
Tried quitting drugsi | 4.72 | 2.79 | 1.69 | −0.75, 10.19 | 0.092 | 4.98 | 2.85 | 1.75 | −0.60, 10.57 | 0.075 |
Risk factors in the past six months |
Slept on streets for >3 nights | −4.55 | 2.99 | −1.52 | −10.40, 1.31 | 0.130 | - | - | - | - | - |
Daily crack smokingj | −5.95 | 2.56 | −2.32 | −10.97, −0.92 | 0.021 | −5.42 | 2.67 | −2.03 | −10.66, −0.18 | 0.044 |
Injected drugsk | −4.41 | 2.65 | −1.66 | −9.60, 0.79 | 0.098 | −4.12 | 2.75 | −1.50 | −9.50, 1.27 | 0.136 |
Sex work involvement | −4.15 | 3.11 | −1.33 | −10.24, 1.95 | 0.185 | - | - | - | - | - |
Did not always use condoms with casual partners | −0.36 | 4.136 | −0.09 | −8.47, 7.74 | 0.936 | - | - | - | - | - |
Did not always use condoms use with regular partners | 4.48 | 5.10 | 0.88 | −5.52, 14.48 | 0.383 | - | - | - | - | - |
Sexually transmitted infection | −1.16 | 5.04 | −0.23 | −11.04, 8.73 | 0.818 | - | - | - | - | - |
Sexual assaultl | −14.61 | 6.96 | −2.10 | −28.24, −0.98 | 0.037 | −14.42 | 6.97 | −2.07 | −28.09, −0.76 | 0.041 |
Blackouts from drinkingm | −5.75 | 2.65 | −2.17 | −10.97, −0.56 | 0.032 | −6.19 | 2.77 | −2.23 | −11.62, −0.75 | 0.027 |
Binge drinking | −1.54 | 3.11 | −0.49 | −7.63, 4.56 | 0.625 | - | - | - | - | - |
HIV-positive serostatus | −0.18 | 3.85 | −0.05 | −7.73, 7.36 | 0.960 | - | - | - | - | - |
HCV-positive serostatus | 0.32 | 3.05 | 0.10 | −6.63, 6.34 | 0.920 | - | - | - | - | - |
Psychological distress | −1.37 | 1.42 | −0.97 | −4.14, 1.40 | 0.333 | | | | | |
Speaking traditional languages had the strongest positive influence on participants’ resilience over time. Those who currently knew how to speak their traditional language had, on average, resilience scores that were 13.06 points higher (p = 0.001). Additionally, often/always living by traditional culture in the past six months was significantly associated with higher resilience scores (B = 6.50, p = 0.025). In the unadjusted model, participating in traditional ceremonies in the previous six months was significantly associated with an increased mean resilience score. However, the association was no longer significant after adjusting for confounders.
Having accessed drug or alcohol treatment in the past six months was also significantly associated with higher mean resilience scores (B = 4.84, p = 0.036). Further, although having tried to quit using drugs in the past six months was associated with higher resilience in the unadjusted model (B = 4.72, p = 0.092), this association was only marginally significant after adjusting for confounders (B = 4.98, p = 0.075).
Risk factors associated with resilience
Of the five types of childhood maltreatment, only emotional neglect was associated with mean resilience score, with participants who had experienced severe emotional neglect having significantly lower mean resilience scores (B = −13.33, p = 0.001).
For the time-varying risk factors, having been sexually assaulted had the greatest negative effect on participants’ resilience. Participants who reported sexual assault had, on average, mean resilience scores that were −14.42 lower (p = 0.041). In addition, smoking crack daily (B = −5.42, p = 0.044) and having had blackouts from drinking alcohol were both significantly associated with diminished mean resilience scores-(B = −6.19, p = 0.027). Though there was a marginal association between having injected drugs and lower mean resilience in unadjusted analysis, adjusting for confounders attenuated the result.
Acknowledgements
We are indebted to the study participants for their participation in the Cedar Project. Special thanks are due to the Cedar Project Partnership for their conviction and for holding us accountable to the voices of young Indigenous people. To the Elders who support our study, particularly Violet Bozoki and Earl Henderson, thank you for your continued wisdom and guidance. Our study staff, Vicky Thomas, Sharon Springer, Amanda Wood, Nancy Laliberte, Jill Fikowski, Shawna Morrison, Matt Quenneville, Jillian Watson, and Lindsay Seaby must be thanked for their conviction and contributions. The Cedar Project receives ongoing support from the Canadian Institutes of Health Research (Application #272441), which has no role in the preparation of data or manuscripts.
Vancouver Native Health Society; Canadian Aboriginal AIDS Network; Carrier Sekani Family Services; Positive Living North; Prince George Native Friendship Centre; Red Road HIV/AIDS Network; All Nations Hope; Splatsin Secwepemc Nation; Neskonlith Indian Band; Adams Lake Indian Band.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
MEP was responsible for the conception of the research question, statistical analysis, interpretation, and drafted the manuscript. KJ made significant contributions to the data interpretation and drafting of the work. CR made intellectual contributions to the content of the paper and interpretation of the data. EWH and SP made significant intellectual contributions to the interpretation of the analysis and drafting of the work in addition to providing cultural guidance. EOJ made intellectual contributions to the content of the paper and interpretation of the data. WC contributed to the data analysis and the draft of the work. MTS and PMS made essential contributions to the analysis and interpretation of the study and made critically important contributions to the intellectual content. Each author gave their final approval to this version of the manuscript to be published.
MEP recently completed her PhD at the University of British Columbia (UBC) School of Population and Public Health (SPPH); KJ is a PhD candidate at UBC-SPPH and a trainee with the Centre for Health Evaluation and Outcome Sciences (CHEOS); CR is an Associate Professor at UBC-SPPH and a Research Scientist with CHEOS; EWH has Cree and Métis Ancestry, is an Elder and Knowledge Keeper, and an Adjunct Professor at the University of Northern British Columbia; SP is Cree, a Research Manager at the Canadian Aboriginal AIDS Network, and a Sessional Instructor at the University of Victoria in British Columbia; EOJ is an Associate Professor at UBC-SPPH and Research Scientist at CHEOS; WMC is from Splatsin Secwepemc Nation and is the elected Kukpi7 (Chief) of his community; MTS is the Chief Scientific Officer at the Michael Smith Foundation for Health Research and a Professor at UBC-SPPH; PMS is the Interim Associate Director of Research at the UBC Centre for Excellence in Indigenous Health, a Professor at UBC-SPPH, and a Research Scientist at CHEOS.