The 577+ American Indian and Alaska Native (AI/AN) tribes and communities throughout the U.S. are diverse in their language, culture, traditions, spiritual practices, and heritage. This diversity must be considered when developing and utilizing measures to assess the effectiveness of health and educational programs, interventions, and policies. AI/AN youth under 18 years old make up about 29% of the AI/AN population–too many experience poor mental health outcomes resulting from disproportionate exposure to historical trauma and other social, structural, political, and environmental factors [1]. As a result, AI/AN youth are placed at greater risk for suicide, poor mental health, depression, and substance misuse [2].

Culturally-adapted evidence-based interventions (EBIs) are emerging as an essential tool for building health equity in AI/AN populations [3]. Assessing the validity of instruments that document the characteristics of program participants and program impact is essential. Without valid instrumentation, it is nearly impossible to know if an intervention worked, for whom, and in what context. For decades, researchers, policymakers, educators, and interventionists have been challenged with data collection in AI/AN populations, including restricted data access, limited capacity to analyze data, difficulty finding comparison groups, limited quality data, small sample sizes, lack of national AI/AN samples, limited comparison groups, lack of cultural validity, and varying levels of programmatic capacity [4–5]. Researchers often use assessment instruments designed for the general population in AI/AN contexts–often, these lack cultural context or community feedback [5]. Developing valid instruments with AI/AN communities requires an understanding of differences in views about what determines health and wellness and the unique community and cultural practices that protect youth. The language and terms used to define health outcomes in mainstream survey tools may be based on western medialized constructs that have little relevance in AI/AN community settings [5]. Researchers working with AI/AN communities to evaluate health programs and interventions need to reliably measure risk and protective factors among program participants. In this review, protective factors refer to conditions or variables that may increase positive health outcomes in AI/AN youth.

Research suggests that self-esteem, social support, community connections, and culture may be protective [6]. Self-esteem has been associated with school success, internal locus of control, perceptions of competence, social support, and coping skills [7]. Peer and family social support has been inversely correlated with AI/AN youth substance misuse [8]. Family caring has been associated with positive AI/AN youth mental health [9]. Cultural connectedness has been associated with academic success and resilience [10]. One study found that AI/AN youth with an interest in their culture were less likely to display violent behaviors [11]. Stable community conditions may foster healthy connections and safety [8, 12], which may be protective against substance misuse and suicide ideation. Such research demonstrates forward progress in understanding what determines health in AI/AN youth. Still, more work is needed to capture the strengths of AI/AN youth and communities through the development of valid survey measures.

Attempts to measure protective factors such as self-esteem, social support, community, and culture are evident in standardized assessments, but few have been developed with AI/AN youth in mind. First, Rosenberg’s self-esteem scale has been used to assess participant self-esteem characteristics in the general population [13]. Second, Zimet and colleagues developed a Multidimensional Perceived Social Support scale [14]–which is widely used in the health programming milieu. Unlike social support and self-esteem, where standard mental health assessments are used or adapted, assessing aspects of culture and ethnic identity requires a different approach. Snowshoe and colleagues developed the Cultural Connectedness Short Scale (CCSS) to measure culture in First Nations youth [15]. The CCSS is meant to be adapted by First Nations and Native communities based on their unique culture, traditions, and context. Importantly, culture and community depend on values, history, traditions, customs, sense of belonging, and membership–the construct of culture is often defined and conceptualized with a specific community in mind [16].

Future efforts can build on this preliminary work, measuring protective factors in AI/AN youth that promote health and healthy decision-making [21]. For example, researchers may consider more comprehensive survey measures that define and operationalize culture and Native American identity, for example, creating culture-specific questions about involvement in history, traditions, and customs of a specific tribal group. At the individual level, future protective and strength-based surveys may include questions about healthy coping and problem-solving skills, emotional self-regulation, academic achievement, and positive physical development [7]. At the community level, additional questions could expand on the role of school, neighborhood, and community while documenting the presence of mentors, support, positive norms, behavior expectations, and safety [6]. Family strengths and protective factors are also essential, and documenting how the family provides structure, limits, rules, monitoring, predictability, supportive relationships, and behavior expectations is warranted. The Native STAND team encourages researchers, policymakers, programs, communities, clinicians, and educators to consider what is protective and what questions are essential to a program or study. Meeting with communities and members of the focus population can help define what wellness, health, culture, and community looks like and create surveys that build on these strengths and resources [5]. Although the Native STAND survey does not capture every strength-based measure possible, it is a starting point for documenting the strengths and needs of AI/AN youth throughout the life course.