With less than 15% of American Indians and Alaska Natives earning a four-year college degree, tribal colleges and universities (TCUs) hold promise as culturally specific institutions to help bridge this gap. Originally developed to provide an alternative to Western educational methods, TCUs aim to connect cultural knowledge and wellness through research, academic, and community program development (Guardia & Evans, 2008; Crazy Bull, 2013). TCUs offer culturally enriching classes and programs that are centered on Native communities (US Dept of Education, n.d.). Scholars have described tribal colleges as “institutionalized avenues of cultural brokering” where students learn to “balance the integrity” of their two cultures: Native and American (Gagnon, 1997, p. 15; Guardia & Evans, 2008).

TCUs are also unique institutions within the higher education landscape. The first tribally chartered college, Navajo Community College (now Diné College), was established in 1968 within the Navajo Nation (AIHEC, 1999), which was soon followed by Sinte Gleska College (now Sinte Gleska University) in Mission, South Dakota; Oglala Sioux Community College (now Oglala Lakota College) in Kyle, South Dakota; Turtle Mountain Community College in Belcourt, North Dakota; Standing Rock Community College (now Sitting Bull College) in Fort Yates, North Dakota; and D-Q University in Davis, California. These “original six” tribal colleges established the American Indian Higher Education Consortium (AIHEC) in 1973 (Pease, 2016). In the Higher Education Act, tribal colleges fall within the minority-serving institution category and through the Tribally Controlled Colleges and Universities Assistance Act of 1978, they secured funding to cover laboratory equipment, maintenance and construction efforts, and, ultimately, faculty. Presently, there are 35 accredited TCUs within the United States with the majority in the Northern Plains, Great Lakes, and Southwest regions of the country. TCUs enroll roughly 17,000 students annually with an increasing enrollment growing by 23% from 2000-2016 according to the Status and Trends in Education of Racial and Ethnic Groups’ 2018 report. However, enrollment dropped in the fall of 2020 according to data collected by AIHEC, likely a result of the COVID-19 global pandemic (Thompson, 2021). All TCUs offer associate’s degree programs, with 14 offering bachelor’s degrees and 5 offering master’s degrees (AIHEC, n.d.). While TCUs are not exclusively for students who identify as American Indian or Alaska Native, only 22% of TCU total enrollment identify as non-Native (US Dept of Education, 2018).

AIHEC was founded by the original six TCUs as a support network to influence federal policies and assist TCUs. According to AIHEC, the overarching mission of tribal colleges and universities is to provide high quality education and successful outcomes based in the foundation of culture and tradition. Key benefits of TCUs for American Indian and Alaska Native students include offering access to higher education, preserving tribal languages and culture, responding to unique needs of their students through the provision of transportation and daycare centers, providing seamless learning opportunities between local tribal communities and universities, and ultimately helping to prepare students for the transition to four-year institutions off the reservation (Guardia & Evans, 2008). Each TCU was created by their respective tribal government in order to provide culturally grounded and holistic higher education opportunities to Native people (AIHEC, n.d.).

Given the key attenuation to supporting students at TCUs, behavioral health initiatives for Native students at TCUs can be presumed to be superior to those at predominantly white institutions (PWIs) because of their focus on improving well-being while centering culture. Behavioral health at TCUs is defined as the environment surrounding one’s emotional, spiritual, and mental health (Crazy Bull, 2013). The majority of behavioral health initiatives at tribal colleges are based on traditional knowledge (Crazy Bull, 2013). While early behavioral health research at TCUs focused on government policy and socioeconomic conditions related to the quality of life on reservations (Crazy Bull, 2013; Pavel et al., 2001), present day work has shifted focus to mainly substance abuse and its consequences and related policy development. Based on a 2013 report from Duran and colleagues at the Indigenous Wellness Research Institute in conjunction with 26 TCUs, research has not yet established behavioral health trends among TCU students (Duran et al., 2013).

Methods

The purpose of this article is to examine what is currently known about behavioral health among TCUs. Specifically, this study examines the existing data and trends on the behavioral health of TCU students; the best practices for prevention, early intervention, or treatment of behavioral health; and finally, we seek to identify gaps and emerging practices warranting additional investigation. From January to February 2020, we searched a range of peer-reviewed journal databases including MEDLINE, SocINDEX, Academic Search Premiere, and PsychINFO from the EbscoHost database according to specific inclusion and exclusion criteria. Key search terms included “tribal college” or “tribal university,” in addition to extensive behavioral health-related terms. We further refined our search through the inclusion of terms related to programs, policies, and other public mental health efforts on campus. This review was restricted to peer-reviewed publications from within the previous 10 years to capture a current picture of behavioral health at TCUs. As such, articles published before 2010 were excluded from this scoping review. Editorials, position papers, blogs, and other grey literature such as working papers, newsletters, and white papers were considered outside the scope of the present paper. Similarly, any material published outside of the United States was not considered in this work.

Preliminary search results of peer-reviewed journal articles on topics of behavioral health research among TCUs yielded a total of 90 articles. Upon examination and application of search criteria, a total of seven articles were included within the present review, as seen in Figure 1. While findings may appear to be based upon a small number of articles, these articles are similar to previous work with American Indian and Alaska Native communities (blinded for peer review; Gone & Alcantara, 2007).

Results

Seven articles met the inclusion criteria related to TCUs. Three were policy and design-related and the remaining four discussed results on alcohol and tobacco use. Only two of the seven articles referenced programs or interventions. Overall, there were no randomized controlled trials or experimental designs utilized. Crazy Bull (2013) broadly reported on the connection between culture and behavioral health by discussing themes central to developing studies of behavioral health at TCUs. The remaining studies included empirical evidence in the evaluation of related topics measuring either tobacco or alcohol use or outcomes from various programs or policies at TCUs.

Tobacco

There is very limited information available regarding Native college student smoking behaviors. Existing literature indicates that Native people have the highest smoking rate (40%) compared to any other ethnic group (Faseru et al., 2010). This is further complicated as American Indians and Alaska Natives report experiencing greater difficulty in quitting and are among the least successful in maintaining abstinence (Faseru et al., 2010). More representative studies are needed to understand the smoking behaviors of Native college students. Faseru and colleagues (2010) described a proposed longitudinal cohort study; please see Choi et al. (2016) and Pacheco et al. (2018) for the results of this study.

The Tribal College Tobacco and Behavior Survey (TCTABS) was a prominent finding in the consideration of behavioral health at TCUs (Choi et al., 2016; Faseru et al., 2010). The TCTABS was designed to improve understanding of health behaviors, particularly smoking, among American Indian TCU students and what factors can contribute in creating a more effective program to prevent and intervene in recreational smoking (Choi et al., 2016). A total of 1,256 freshman from tribal colleges in the Midwest and Northern Plains were recruited; data were collected from 2011-2014 with the average student participating in the study being 25.5 years old and predominantly female (57.8%). Moreover, participating students grew up on either reservation or tribal trust land (61%) and were enrolled in a four-year program (59%).

Results of the TCTABS found that roughly 35% of participants smoked tobacco (Choi et al., 2016). Participants from the Northern Plains, male participants, and students with children all had higher rates of smoking. Further, students that grew up on tribal lands had significantly higher rates of smoking when compared to other areas of residence while students working towards a four-year degree had lower smoking prevalence (Choi et al., 2016). The TCTABS revealed that the mean age of students identifying as a “smoker” did so around the age of 17, with the age at first use reported as 14 (Choi et al., 2016).

TCTABS found split results in the role of college and smoking cessation. Among all smokers, most reported a smoking decrease since enrolling in college (36%). However, 30% reported an increase in smoking and the remainder (34%) reported no change in smoking behavior (Choi et al., 2016). The majority of students reported at least one attempt to quit within the last year (62%) and most wanted to quit on their own (62%) (Choi et al., 2016). Finally, most students, including smokers and non-smokers alike, estimated that the current smoking prevalence on campus was more than 41% of all students, with rates of perceived smoking prevalence as high as 61% (Choi et al., 2016), indicating that the majority of students believe that smoking is moderately common.

Results of the TCTABS are consistent with other smoking prevalence research among Native adults, although research among Native TCU students is scarce. As of 2022, five of the 37 tribal colleges have smoke-free campuses, both indoors and out (ANRF, 2022) (see Table 1 below). Smoking is a highly visible behavior and may reflect a cultural norm among Native communities. Future work is needed to discern the role of tobacco in recreational and traditional use among American Indian and Alaska Native adults. Findings call for more research among health-related behaviors, particularly smoking, as it is one of the most preventable causes of death (Choi et al., 2016). Since most students reported a decrease in smoking since enrolling in college, addressing motivation to quit smoking during recruitment could be beneficial. Lastly, most participants reported that the ethnic background of the person helping them quit was not important, indicating that smoking cessation work programming matters more than the programmer.

*Note: Data from ANRF, 2022 report: Smokefree and Tobacco-Free Tribal Colleges and Universities

            While not uncovered within the original search, the Leech Lake Tribal College prohibits all commercial tobacco use across campus, as seen in Table 1; however, the role of asemaa (tobacco) as medicine is strongly encouraged and supported (Bosma & Hanson, 2017). Inaugural president and founder of Leech Lake Tribal College, Larry Aitken stated, “You must always have asemaa to prepare for anything that you do, as everything in your life requires preparation” (Bosma & Hanson, 2017). While the path to balancing sacred and commercial tobacco use has not been easy, LLTC made sure to take the time to both educate about the harmful nature of commercial tobacco while simultaneously honoring and upholding the sacred and ceremonial uses of asemaa (Bosma & Hanson, 2017). LLTC’s commercial tobacco-free campus policy holds promise in leading the way for other TCUs to follow suit.

Alcohol

One study reported on alcohol use among TCU students. Larimer and colleagues (2019) reported results from a survey sampling over 3,000 students across 22 tribal colleges and universities from 2015-2016, examining alcohol use, norms, and alcohol-related consequences. Results of the study indicate that students misperceive descriptive norms by estimating that fellow students drank more frequently, drank more per occasion, and had more drinks per week (Larimer et al., 2019). Participant drinking was related to perceived norms, with students that had higher perceptions reporting more drinking and more alcohol-related negative consequences (Larimer et al., 2019). Results of this study extend research at similar minority-serving institutions, supporting interventions to emphasize healthy alcohol norms and correct common misconceptions that most college students are drinking to the point of excess.

Programs and Policies

The remaining three articles discussed programs and policies at tribal colleges and universities. Pacheco and colleagues (2018) expanded on the previously mentioned work by Faseru et al. (2010) and Choi et al. (2016) by disseminating further results of the TCTABS, particularly regarding support and awareness of smoke-free campus policies. Results of the study were based on 1,256 American Indian students aged 18 or older enrolled in one of three participating tribal colleges, with outcomes focusing on smoking policy awareness, exposure to secondhand smoke, intention to quit smoking, and smoking on campus (Pacheco et al., 2018). The majority of students reported being around smokers within the past seven days (58%) or spending most of their time around smokers (54%). Regarding awareness of collegiate smoking policy, most students were correct in identifying smoking policies, with most reporting they learned about the policy via written communication (Pacheco et al., 2018). Both smokers and non-smokers alike indicated a strong preference for a smoke-free campus, with smokers that planned to quit within the next 30 days indicating significantly greater likelihood to want a smoke-free campus at their institution (Pacheco et al., 2018). Overall results of the study promote the adoption of smoke-free policies, including visible signs as well as enforcement of policy rules (Pacheco et al., 2018). Future studies should continue this work in determining the impact of secondhand smoke and smoking policies among TCUs.

Bordelon and Atkinson (2020) conducted a qualitative examination with students, faculty, and administration members at the Little Big Horn College located on the Crow Indian Reservation. The study reported on the major impact TCUs have upon the economic development of their surrounding community, positing how TCUs are often the repositories for the language and culture of the tribe that chartered the institution. Compared to other universities, most TCUs do not offer the array of bachelor’s, master’s, or doctoral programs in many disciplines and professions. Two focus groups and follow up interviews were conducted with 21 students, 8 faculty members, and 2 administrators with the intent to create a pathway towards a Bachelor of Social Work degree. Three main themes emerged: 1) continuing support from beginning to end of the program, 2) the need to address financial concerns, and 3) offering guidance and social support (Bordelon & Atkinson, 2020). While the description of tribal colleges and universities’ economic impact on the surrounding community was a valuable contribution and met search criteria, the focus was more on program development for behavioral health training rather than addressing the behavioral health of TCU students.

The final study reported on media-driven technology to promote health and reduce risk among Native students (Sabato, 2018). A total of 210 TCU students completed an online survey examining effective technology and interventions related to health-seeking patterns and preferences focusing on substance use disorders, depression, and risky sexual behaviors, including measures of technology use, interest, and experience in accessing health information online (Sabato, 2018). Results suggest that technology-based interventions are promising avenues to address the unique worldviews and social contexts for Native youth aged 18-24 (Sabato, 2018). Findings of this study contribute innovative information on promising practices for prevention and early intervention through the utilization of technology.

Discussion

This scoping review sought to examine current peer-reviewed literature on behavioral health at tribal colleges and universities with a particular focus on existing data and trends, subsequent gaps in the literature, best practices, and emerging practices for future investigation. Among peer-reviewed literature on TCUs within the past decade, the TCTABS emerged as the most prominent behavioral health-related research that met search criteria for the present review, contributing to three of the seven included studies. The sole study examining alcohol use that our research uncovered was focused on the perception of peer norms and relationships rather than the prevalence or related academic and wellness outcomes.

Remaining studies indicate a variable research base regarding behavioral health among TCUs, with little to no stratification by various demographics or identities such as sexual orientation or veteran status. No published peer-reviewed studies that we discovered examined illicit drugs or marijuana, despite their increased prevalence among college students in general. Similarly, behavioral health research consists of more than just tobacco and alcohol use, yet no published peer-reviewed studies that we uncovered examined HIV/AIDS, risky sexual behaviors, or any examination of mental health issues. Finally, prevention and intervention studies were largely absent overall, with no relevant literature identified pertaining to public mental health efforts on campus such as community services or stigma reduction at TCUs.

While not uncovered within the original search, equine-assisted psychotherapy is a behavioral health intervention among TCUs as evidenced by the Nueta Hidatsa Sahnish College’s (NHSC’s) Horse Nation Initiative (White Plume, 2016). Through the combination of both psychology and animal science courses with experiential learning, students at the NHSC are able to connect with the horse nation “spirit to spirit” (White Plume, 2016). Extending their work with the horse nation beyond the college, NHSC offers a community outreach program that includes highly attended family horsemanship classes and related partnerships with community groups. Researchers have found considerable change in both the scientific community and the community-based research outcomes (White Plume, 2016). Overall, horse culture-based healing as a behavioral health intervention is part of the larger movement to reclaim and redefine healing and wellness within Native nations and across Indian Country.

Tribal colleges and universities are bastions of cultural knowledge and represent a culturally grounded alternative to Western methods of education, making space for Native students to remain connected to their culture while achieving academic success in higher education. Future work should consider the unique role that TCUs can play in the promotion of behavioral health among Native students. Because of the national structures and locations of TCUs, these systems are ideal for random control trials focused on testing well-established and emerging evidence-based interventions addressing general health and wellness of Native student populations (Gilder et al., 2017).

Further, because a college degree has been found historically to be a protective factor for lifetime health, wellness, and finical condition, TCUs could lead the way in science development related to college retention interventions. Having discovered the benefits of social belonging interventions for under-represented minorities remaining in higher education at urban colleges or universities (blinded for peer review), additional work is needed for students attending TCUs.

Conclusion

This first-of-its-kind scoping review focused specifically on behavioral health among tribal colleges and universities. It is an important step in understanding the barriers and pathways toward health for individuals enrolled in our nation’s TCUs. Given that the tribal college tobacco and behavior survey was the most recent and possibly singular tool and study evaluating health conditions throughout the TCU system, more scientific investigations are needed. However, the LLTC commercial tobacco-free campus policy provides a pathway forward for tribal colleges and universities to follow suit. As we move toward more equitable outcomes in higher education (Cuellar & Gandara, 2020), existing TCU educational infrastructure is fertile investigative ground to achieve this important goal.   

Autumn Asher BlackDeer, MSW, PhD Candidate; David Patterson Silver Wolf, PhD; Sara Beeler-Stinn, PhD, LCSW, MPA; Jen Van Schuyver, MSW

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