The use and impact of digital technologies for and on the mental health and wellbeing of Indigenous people: A systematic review of empirical studies
Introduction
High rates of suicide, depression, substance abuse, and violence are prevalent among Indigenous people globally (Black et al., 2015; Kisely et al., 2017; Pan American Health Organization, 2016; Pollock, Naicker, Loro, Mulay, & Colman, 2018). Historical displacement from tribal lands, treaty abuse, residential school attendance, and destruction of families have contributed to Indigenous mental health challenges, along with other adverse intergenerational biological consequences, economic disparity, and geographical isolation (Brave Heart & DeBruyn, 1998; Brown, Dickerson, & D'Amico, 2016; Duran & Duran, 1995; Moon-Riley, Copeland, Metz, & Currie, 2019; Elias et al., 2012).
Indigenous people—defined on page eight—are especially vulnerable to mental health problems (Carlson, Farrelly, Frazer, & Borthwick, 2015; Elias et al., 2012; Stewart, 2008). After a systematic review that included 99 studies examining suicide rates among Indigenous people across 30 countries and territories, Pollock et al. (2018) found “evidence of suicide rate parity between Indigenous and non-Indigenous populations in some contexts, while elsewhere rates were more than 20 times higher among Indigenous peoples” (p. 1). Further, alcohol consumption rates are higher among American Indian/Alaska Native (AI/AN) youth than that of youth nationwide (Stanley, Harness, Swaim, & Beauvais, 2014). A study in Western Australia revealed that Aboriginal youth were at significantly higher risks of mental health difficulties than non-Aboriginal youth, but Aboriginal youth were less likely to seek mental health services (De Maio et al., 2005). Research has shown that mental health services are rarely sought by Indigenous people due to the inaccessibility of mental health care professionals, fear and mistrust of government services, fear of inaccurate or exaggerated diagnoses, feelings of shame associated with help-seeking, and discomfort disclosing sensitive issues to a community member (Farrelly, 2008; Price & Dalgleish, 2013; Williamson et al., 2010).
Recent research has revealed that Indigenous communities, particularly Indigenous youth, can overcome the digital divide with mobile technology advances, and actively adopt digital technologies in their daily lives compared with older Indigenous generations. A national survey in the United States reported that 78% of 675 AI/AN teenagers and young adults had regular access to a smartphone (Rushing, Stephens, & Dog, 2018). More than 90% of 210 AI/AN youth participants in Sabato’s (2019) study used computers and cellphones on a daily or weekly basis, which was similar to or exceeded the use of their non-Native counterparts in the United States. Further, according to Sam, Wisener, Schuitemaker and Jarvis-Selinger's (2018) study, First Nations, Mtis and Inuit (FNMI) youth spent two to eight hours online each day. Many Indigenous people, particularly youth and young adults, are avid users of computers, laptops, tablets and smartphones, and were found to be well-informed and frequently engaged with several social media platforms including Facebook, YouTube, Twitter, Snapchat, and Instagram, with Facebook being the most widely used (Castleton, 2018; Gritton et al., 2017; Loebach, Tilleczek, Chaisson, & Sharp, 2019; Sam, Wisener, Schuitemaker, & Jarvis-Selinger, 2018).
An increasing body of research suggests that digital technology has great potential to facilitate mental health promotion, education, and treatment for Indigenous people of various ages. A randomised controlled trial (Toombs et al., 2020) and an observational cohort study (Titov, Schofield, Staples, Dear, & Nielssen, 2019) found that e-mental health (eMH) apps, such as ibobbly and MindSpot were effective in providing treatment for Indigenous Australians, reducing symptoms of anxiety, stress, distress and depression on post-treatment measures. Titov et al. (2019) also reported large effect sizes in their assessment measures for Indigenous Australian patients. An uncontrolled study using the AIMhi Stay Strong App found that perceived knowledge and confidence in eMH were improved significantly after training (Dingwall et al., 2015a).
Digital multimedia technologies have also enabled several story-telling activities that support Indigenous youth in Canada to articulate and understand their struggles related to their Indigenous identity and explore the meaning of wellbeing, thus promoting their mental health (Loebach et al., 2019; Riecken, Scott, & Tanaka, 2006; Stewart, Riecken, Scott, Tanaka, & Riecken, 2008). Carlson et al. (2015) suggest that Indigenous people are more receptive to informal help-seeking methods, such as digital media use, which may help them overcome various barriers preventing them from seeking formal mental health help. Mobile technology has great potential to deliver mental health programs, services and interventions to Indigenous people who struggle with mental health.
Therefore, in order to provide insights for the development of future interventions and pedagogical practices and inform further research, a systematic literature review is needed. Such a review would examine the evidence and potential of using diverse digital technologies to specifically improve the mental health of Indigenous people of all ages across countries. This review is needed because we were only able to locate a few literature reviews with a related focus, for example: a) Pollock et al.’s (2018) systematic review that examined suicide rates of Indigenous people in 30 countries and territories, b) Kisely et al.’s (2017) systematic review and meta-analysis focused on depression and anxiety disorders in Indigenous people of the Americas (Latin America, Canada, and the United States), c) Black et al.’s (2015) systematic review examined rates of psychiatric disorder in Australia's Indigenous populations, d) Hensel, Ellard, Koltek, Wilson, and Sareen (2019) focused on reviewing evidence and examples of digital health solutions for Indigenous mental well-being, including “remote access to specialists,” “building and supporting local capacity,” and “patient-directed interventions” (p. 1), and e) Toombs et al.’s (2020) systematic review included studies on electronic mental health interventions for Indigenous youth using Internet and related technologies.
While these reviews provided important and relevant information in Indigenous contexts, they focused on either the situation of Indigenous people's mental health, or exclusively on Indigenous youth's mental health issues. Given the severe mental health challenges faced by Indigenous people at all ages and increasing acceptance and use of digital technology in Indigenous communities, a systematic review is needed to examine empirical evidence from research using quantitative and/or qualitative methods to study the use of diverse technologies to address an array of mental health challenges of Indigenous people of all age ranges. This review aims to provide thorough and updated information in research and intervention designs—with varied Indigenous participants, technology scaffolding, mental health issues, and research methods—that have not been provided in previous reviews.
This paper aims to assess research evidence from literature regarding the impact and use of digital technologies for the mental health of Indigenous people. Our five research questions are as follows:
- 1.
What digital technologies have (a) Indigenous people used for mental health purposes or (b) researchers, health professionals, and other stakeholders used to facilitate Indigenous mental health promotion and services?
- 2.
What key mental health issues have (a) Indigenous people or (b) researchers, health professionals, and other stakeholders addressed using digital technologies?
- 3.
What measurable outcomes, if any, have resulted from using eMH resources, including apps, programs, or services, to support Indigenous people's mental health?
- 4.
What are Indigenous people's perspectives on using digital technology to support mental health, including self-initiated help, eMH services, and intervention projects?
- 5.
What are mental health professionals and other stakeholders' perspectives on using digital technology to support Indigenous mental health?
The authors of this review are first- and second-generation Canadian women of colour. Both are visible minorities and non-native English speakers whose personal, academic, and professional experiences have facilitated their passion for helping marginalized communities in the areas of language, literacy, and mental health. The first author's work has been focused on developing culturally responsive language and literacy instructions for linguistically diverse Indigenous and new immigrant adolescents and young adults from low-income families. At present, we collaborate with First Nation educational partners, Elders and community cultural workers, literacy and language researchers, clinical psychologists, and computer scientists on a cross-disciplinary Indigenous project funded by the Social Science and Humanities Research Council of Canada. During this digital technology-based intervention project, we worked closely with Indigenous youth and community members and witnessed firsthand their struggles with mental health and the associated effects on daily living. We recognized that Indigenous mental health challenges are the consequences of a shared history of colonization and subsequent intergenerational trauma that are deeply rooted in Indigenous culture and communities, where there is also a lack of access to culturally safe health and wellness resources. Therefore, we believe that our current project to help Indigenous youth learn content-based literacy can only be accomplished with an in-depth understanding of Indigenous mental health issues and the role of technology in these communities. We are cautious of our non-Indigenous identities and strive to conduct research with the utmost respect for Indigenous cultural practice, preservation, and continuity. This entails responding to the needs defined by Indigenous communities, without imposing Western-informed ideologies, concepts, standards, protocols, assumptions, and interpretations.
This review draws upon relevant research on all Indigenous people. This includes, but is not limited to, the following populations: FNMI in Canada, Mi'kmaq First Nations in Canada, AI/AN in the United States, Aboriginal Australians, Torres Strait Islander people in Australia, Māori people in New Zealand, and Pacific people in New Zealand. The term “Indigenous” is used in this paper to refer to all and any of these populations, following “a modern understanding” of this term suggested by the United Nations Permanent Forum on Indigenous Issues (n.d.). When reviewing a specific article, specific Indigenous populations, such as “Aboriginal” or “First Nations” are referenced following the original study.
Remote communities are those that are only accessible by air or water or seasonally accessible by road (Chandler & Lalonde, 1998).
Digital technologies are electronic tools, such as smartphones, laptop computers and tablets, that enable access to digital media (Rice, Haynes, Royce, & Thompson, 2016). At a minimum, all studies included in this review focus on at least one type of digital technology or digital media.
This paper adopts the description of digital media by Loebach et al. (2019). According to their participants, Mi'Kmaq First Nation youth from a remote island in P.E.I, Canada, digital media include:
…all social networking communication and instant messaging (using multiple applications such as Facebook, Instagram, Snapchat, and Twitter), texting, emailing, and video chatting (using platforms such as Skype or FaceTime), as well as watching online video content (through platforms such as YouTube). To these youth, “digital media” also refers to gaming with online games, including those which allow you to play and communicate remotely with multiple other players in real-time … Digital media [also] incorporates acts of listening to, learning, or producing music, art and film. (p. 287)
This review addresses the mental health challenges of Indigenous people, such as suicide, depression, and substance abuse. Mental health issues in Indigenous contexts can be described as
…the lack of balance between physical, emotional, intellectual and spiritual development in one's life. Inner peace reflects relative balance. Mental illness is the outcome of a lack of balance within a person, often due to overwhelming experiences and/or deprivation and the absence of external resources offering safety and opportunity for meeting needs and restoring functions. (Canadian Collaborative Mental Health Initiative, 2006, p. 3)
Section snippets
Selection criteria and procedures
This systematic review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA; Liberati et al., 2009). Upon consulting the Social Science, Humanity, and Education librarian at the university of the authors' affiliation, a review protocol was developed to guide the literature search, containing information of the search terms, search tools (databases and search engines) and screening criteria. We systematically searched for full-length
Participant identities and countries of residence
The 27 studies reviewed were conducted in four countries: Australia, Canada, the United States, and New Zealand (see Fig. 2). Nearly half of the studies (n = 13) were conducted in Australia with Indigenous people and their health and mental health service providers and stakeholders. Almost one-third of the studies (n = 8) were conducted with Indigenous people and mental health providers in Canada. A few studies focused on AI/AN in the United States (n = 4), while two studies occurred in New
A holistic approach to Indigenous mental health using digital technology: Identity empowerment through culturally appropriate strategies
Many of the studies indicated that a primary contributing factor to Indigenous people's, particularly youth's, mental health and healing is a strong sense of identity deeply rooted in Indigenous culture; that is, self-representation, self-esteem, spirituality, Indigenous knowledge, and community bonds (e.g., Carlson & Frazer, 2015; Loebach et al., 2019; Riecken et al., 2006; Stewart et al., 2008). Williamson et al.’s (2010) study showed that Indigenous youth's mental health can be improved by
Conclusion
To conclude, this review is significant in providing a systematic synthesis of empirical evidence relating to the implications of Indigenous people's use of digital technology for mental health, and the feasibility of eMH services and programs from the viewpoints of Indigenous people themselves and other important stakeholders. Despite some challenges, digital technology presents promising opportunities to improve the mental wellbeing of Indigenous people. Many Indigenous communities across the
Credit author statement
Jia Li: Conceptualization, Methodology, Validation, Formal analysis, Visualization, (Most) Writing - Original draft, Writing - Review & Editing, Supervision, Project administration. Amareeen Brar: Formal analysis, Visualization, (Section) Writing - Original draft, (Assisting) Writing - Review & Editing.
Declaration of competing interest
Authors declare that they have no conflicts of interest.
Acknowledgement
The project was supported by a grant from the Social Sciences and Humanities Research Council of Canada and the Zilinsky Graduate Scholarship.
The authors would like to thank the editor, Dr. Andrew Lepp, and the anonymous reviewers for their feedback and suggestions during the revisions of the article. The authors would like to express gratitude to Chelsie Lalonde, Librarian at Ontario Technology University for her assistance in literature search. Our thank-you also goes to Rodney K. Cheung for
References (77)
- et al.
Trauma and suicide behaviour histories among a Canadian Indigenous population: An empirical exploration of the potential role of Canada's residential school system
Social Science & Medicine
(2012) - et al.
A brief screening tool for suicidal symptoms in adolescents and young adults in general health settings: Reliability and validity data from the Australian National General Practice Youth Suicide Prevention Project
Behaviour Research and Therapy
(2002) - et al.
The prevalence of depression and anxiety disorders in indigenous people of the Americas: A systematic review and meta-analysis
Journal of Psychiatric Research
(2017) - et al.
How marginalized young people access, engage with, and navigate health-care systems in the digital age: Systematic review
Journal of Adolescent Health
(2018) - et al.
The protective role of optimism and self-esteem on depressive symptom pathways among Canadian Aboriginal youth
Journal of Youth and Adolescence
(2013) Estimates of Aboriginal and Torres Strait islander Australians
(2018)- et al.
‘It is medicine’: Narratives of healing from the aotearoa digital storytelling as indigenous media project (ADSIMP)
Psychology & Developing Societies
(2014) - et al.
Translating e-mental health into practice: What are the barriers and enablers to e-mental health implementation by Aboriginal and Torres Strait Islander health professionals?
Journal of Medical Internet Research
(2017) - et al.
Diversity in emental health practice: An exploratory qualitative study of Aboriginal and Torres Strait Islander service providers
JMIR Mental Health
(2017) - et al.
A systematic review: Identifying the prevalence rates of psychiatric disorder in Australia's Indigenous populations
Australian and New Zealand Journal of Psychiatry
(2015)