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The Cedar Project: resilience in the face of HIV vulnerability within a cohort study involving young… Pearce, Margo E; Jongbloed, Kate A; Richardson, Chris G; Henderson, Earl W; Pooyak, Sherri D; Oviedo-Joekes, Eugenia; Christian, Wunuxtsin M; Schechter, Martin T; Spittal, Patricia M Oct 29, 2015

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RESEARCH ARTICLE Open AccessThe Cedar Project: resilience in the face ofHIV vulnerability within a cohort studyinvolving young Indigenous people whouse drugs in three Canadian citiesMargo E. Pearce1,2, Kate A. Jongbloed1,2, Chris G. Richardson1,2, Earl W. Henderson3, Sherri D. Pooyak4,Eugenia Oviedo-Joekes1,2, Wunuxtsin M. Christian5, Martin T. Schechter1,2, Patricia M. Spittal1,2*,For the Cedar Project PartnershipAbstractBackground: Indigenous scholars have long argued that it is critical for researchers to identify factors related to culturalconnectedness that may protect against HIV and hepatitis C infection and buffer the effects of historical and lifetimetrauma among young Indigenous peoples. To our knowledge, no previous epidemiological studies have explored theeffect of historical and lifetime traumas, cultural connectedness, and risk factors on resilience among young, urbanIndigenous people who use drugs.Methods: This study explored risk and protective factors associated with resilience among participants of theCedar Project, a cohort study involving young Indigenous peoples who use illicit drugs in three cities in BritishColumbia, Canada. We utilized the Connor-Davidson Resilience Scale to measure resilience, the Childhood TraumaQuestionnaire to measure childhood maltreatment, and the Symptom-Checklist 90-Revised to measure psychologicaldistress among study participants. Multivariate linear mixed effects models (LME) estimated the effect of study variableson mean change in resilience scores between 2011-2012.Results: Among 191 participants, 92 % had experienced any form of childhood maltreatment, 48 % had a parent whoattended residential school, and 71 % had been in foster care. The overall mean resilience score was 62.04, with nodifferences between the young men and women (p = 0.871). Adjusted factors associated with higher mean resiliencescores included having grown up in a family that often/always lived by traditional culture (B = 7.70, p = 0.004) and hadoften/always spoken their traditional language at home (B = 10.52, p < 0.001). Currently knowing how to speak atraditional language (B = 13.06, p = 0.001), currently often or always living by traditional culture (B = 6.50, p = 0.025), andhaving recently sought drug/alcohol treatment (B = 4.84, p = 0.036) were also significantly associated with higher meanresilience scores. Adjusted factors associated with diminished mean resilience scores included severe childhoodemotional neglect (B = −13.34, p = 0.001), smoking crack daily (B = −5.42, p = 0.044), having been sexual assaulted(B = −14.42, p = 0.041), and blackout drinking (B = −6.19, p = 0.027).(Continued on next page)* Correspondence: spittal@sm.hivnet.ubc.ca1School of Population and Public Health, University of British Columbia,Columbia, Canada2Centre for Health Evaluation and Outcome Sciences, 588-1081 Burrard St.,V6Z1Y6 Vancouver, BC, CanadaFull list of author information is available at the end of the article© 2015 Pearce et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (, which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver( applies to the data made available in this article, unless otherwise stated.Pearce et al. BMC Public Health  (2015) 15:1095 DOI 10.1186/s12889-015-2417-7(Continued from previous page)Conclusions: Young people in this study have faced multiple complex challenges to their strength. However, culturalfoundations continue to function as buffers that protect young Indigenous people from severe health outcomes,including vulnerability to HIV and HCV infection.Keywords: Indigenous young people, Resilience, Trauma, HIV and HCV vulnerabilityBackgroundIndigenous scholars agree that although Indigenous civi-lizations are richly diverse, they have also shared com-mon values and beliefs that facilitated healing, positivemeanings, and confidence in the future [1]. Ceremonialmethods for coping with stress in times of adversityenabled Indigenous peoples to process loss and grief [2].Healing traditions were passed down intergenerationallyas parents and Elders used story-telling and experientiallearning to teach young people how to exercise resili-ence, or, find mental, physical, emotional, and spiritualwellbeing when they experienced difficulty [3]. ManyIndigenous cultural practices, languages, and spiritualbeliefs have survived despite 500 years of colonization inCanada. This reinforces the imperative to find alternativesto risk models of disease to identify sources of strength orresilience that may protect the health of young Indigenouspeople in Canada.Colonization in Canada has included forced removalfrom traditional lands, genocide, and legislative measures tosuppress Indigenous cultures, ceremonies, and economicdevelopment [4]. The Gradual Civilization Act of 1857 wasone of the most damaging pieces of legislation as it initiatedthe church-state partnership that established the IndianResidential School System. Between 1874 and 1996, over150,000 Indigenous children were forcibly removed andplaced in residential schools. The system alienated childrenfrom their cultures, languages, and communities in aneffort to Christianize and assimilate them into Canadiansociety [4]. Using corporal and degrading punishments,missionary teachers taught children to be ashamed of theirIndigenous identity. It is estimated that more than 70 % ofchildren in residential schools were routinely abused phys-ically, sexually, or emotionally, in addition to being deprivedof emotional or physical nurturing [4]. When formerstudents returned to their home communities, many facedfeelings of alienation resulting from having lost their con-nection to culture [3]. Further, residential schools severelydisrupted traditional models of child rearing, and manyformer students unintentionally replicated the traumas theyhad experienced within their families and communities.Combined, these experiences prompted a cyclical effect ofintergenerational trauma.Intergenerational trauma is considered one of the mostdisastrous legacies of colonization and the residentialschool system [5]. The ongoing effects are evident withinIndigenous communities that are struggling with interre-lated crises of family violence, poverty, addictions, lackof traditional skills, lack of role models, and feelings ofisolation. Moreover, Indigenous activists and scholarshave maintained that provincial child welfare systems inCanada have perpetuated intergenerational trauma andfragmentation of Indigenous families [6]. Indigenousparents routinely face discrimination and racism withinthe child welfare system, and federal funding incentivizeslong-term separations of Indigenous children from theirfamilies, communities, and cultures [7]. Consequently,though only 7 % of children in Canada have Indigenousethnicity they comprise 48 % of children in the fostercare system [8].Research suggests that young Indigenous people livingwith unaddressed historical and lifetime traumas are morelikely to use illicit drugs as a coping mechanism [9].Further, young urban Indigenous people who use drugs inCanada experience high levels of injection drug use [10],residential transience [11], high risk sex [12], sex work[13], and sexual violence [14]. These cumulative traumashave also manifest as increased HIV and hepatitis C(HCV) vulnerability [15–19]. For example, extant litera-ture has demonstrated that young Indigenous people whouse drugs and have experienced childhood sexual abuseare twice as likely to be living with HIV infection [9], andthose who had at least one parent who attended residen-tial school are twice as likely to be living with HCV infec-tion [20]. Taken together, these vulnerabilities havecontributed substantially to the overrepresentation ofIndigenous people among those living with HIV and HCVinfection in Canada. Recent 2011 data indicates that Indi-genous people constituted an estimated 12.2 % of allpeople in Canada newly diagnosed with HIV, which corre-sponded to an HIV incidence rate that was 3.5 timeshigher than among non-Indigenous people [21]. Likewise,between 2002 and 2008, the estimated incidence of HCVinfection was 4.7 fold higher among Indigenous peoplethan non-Indigenous people [19].In this context of heightened vulnerability, Indigenousleaders have called for recognition of resilience among theiryoung people, including acknowledging strengths-basedfactors that may be protective against HIV and HCV infec-tion [22]. The most widely accepted definition of resiliencein health sciences is positive adaptation despite adversity[23]. Resilience researchers have sought to look beyondPearce et al. BMC Public Health  (2015) 15:1095 Page 2 of 12deficit models of health to identify strength-based resourcesthat promote wellness.However, measures used to assess resilience are oftenlimited because they are based on individualistic outcomesspecifically valued by non-Indigenous cultures, such asself-sufficiency and self-esteem, and narrow definitions ofhealthy functioning, including staying in school andabstaining from substance use [24]. Moreover, resilienceresearch has frequently failed to consider complex histor-ical and cultural contexts when measuring resilienceamong marginalized youth and those outside of the dom-inant culture [25]. It follows that any consideration ofresilience among young Indigenous people in Canadamust acknowledge the historical and present-day injus-tices that impede resilience as well as the culturally-specific community strengths that support resilience [26].A small but growing body of research in Canada hasmoved beyond individualistic, linear, and western notionsof resilience to identify ways in which culture, language,and spirituality buffer adversity and create “cultural resili-ence” among Indigenous peoples [27]. Chandler andLalonde’s [28] study involving 196 Indigenous bands inBritish Columbia (BC), demonstrated that factors associ-ated with ‘cultural continuity’ − including self-governance,band-controlled health and education initiatives, and speak-ing traditional languages −were associated with lower ratesof suicide among Indigenous youth. Very few studies haveexplored the roles that culture and resilience play in thehealth of young, urban Indigenous people. One studyinvolving Indigenous young people in Winnipeg, Canada,found that those who believed it was important to partici-pate in traditional cultural activities scored higher on anemotional competence scale and were less likely to usealcohol or be involved in crimes [29]. Further identifyingsources of resilience may therefore be especially importantfor understanding and responding to HIV and HCV vulner-ability among young urban Indigenous people who usedrugs and who may be disconnected from their home com-munities, languages, cultures, and spirituality [27].To our knowledge no previous epidemiological studieshave explored resilience among young, urban Indigenouspeople who use drugs and experience vulnerability toHIV and HCV exposure within high risk environments.This study sought to investigate the relationship betweenresilience and a range of positive and negative factors,including cultural connectedness, help-seeking, historicaland lifetime trauma, drug- and sex-related risk, and psy-chological distress, among young Indigenous people whouse drugs in British Columbia (BC), Canada.MethodsStudy designThe Cedar Project methods have been described in detailelsewhere [15]. In brief, the Cedar Project is a cohortstudy involving 793 young Indigenous people who useillicit drugs in Vancouver, Prince George, and Chase, BC.Vancouver is a large city in southern BC, on the trad-itional territory of the Coast Salish peoples. Prince Georgeis a mid-sized city in the northern interior of BC, on thetraditional territory of Lheidli T’enneh First Nation. Chaseis a rural town in south-western BC, on the traditionalterritory of Secwepemc First Nation. Participants wereeligible if they self-identified as a descendant of the Indi-genous Peoples of North America; were 14-30 years old;had smoked or injected drugs in the month before enrol-ment, and; provided their written informed consent. Theconsent process involves a thorough conversation betweenthe participant and study interviewer to ensure that theparticipant fully understands the Cedar Project studyrationale and the potential benefits and risks associatedwith being a study participant. This process is the samefor all participants regardless of their age, as outlined inthe BC Infants Act [30]. Since 2003, participants havereturned every six months to complete interviewer-administered questionnaires and provide venous bloodsamples, which are tested for HIV and HCV. Honorariaare provided at each follow-up visit. This analysis includeddata collected between 2003-2012. Indigenous collaboratorsand investigators, collectively known as the Cedar ProjectPartnership, governed the entire research process andapproved this manuscript for publication. The University ofBritish Columbia/Providence Health Care Research EthicsBoard also approved the study.MeasuresResilienceThe Connor-Davidson Resilience Scale (CD-RISC) [31] wasincluded in the longitudinal questionnaires starting in 2011.The CD-RISC is a 25-item self-administered scale designedto measure ability to cope with stress. The scale consists offive factors: 1) personal competence, high standards, andtenacity; 2) trust, tolerance, and strengthening effects ofstress; 3) positive acceptance of change and secure relation-ships; 4) control; and 5) spiritual influences. Responses arerecorded on a five-point Likert scale (not true at all to truenearly all the time). Overall scores are computed by sum-ming all responses, with higher scores indicating greaterresilience. The validity of the CD-RISC has been evaluatedin multiple studies, including research involving youngadults seeking treatment for anxiety related to childhoodmaltreatment [31], and elderly Native Americans in theUnited States [32]. The CD-RISC score was the time-varying outcome in this study for the analysis of resilience.Historical traumaAs in previous studies [9], we used two time-invariantvariables as proxy measures of historical trauma. These in-cluded having at least one parent who attended residentialPearce et al. BMC Public Health  (2015) 15:1095 Page 3 of 12school and ever having been taken away from biologicalparents and placed in foster care.Childhood traumaSince 2011, Cedar Project participants have been offeredthe onetime option of completing the Childhood TraumaQuestionnaire (CTQ) [33]. The CTQ is a widely usedretrospective, self-reported 28-item inventory measuringfive types of childhood maltreatment: emotional abuse,physical abuse, sexual abuse, emotional neglect, and phys-ical neglect [33]. Responses are provided using a five-pointLikert scale according to frequency of experiences (fromnever true to very often true). Due to floor and ceilingeffects for individual scales, subscales scores were con-verted into three levels of maltreatment – none (0), low/moderate (1), and severe (2). Regression coefficients wereinterpreted as the mean change in the resilience score forthe low/moderate levels vs. none and severe vs. nonelevels of maltreatment.Other study variablesIndependent study variables for this analysis were chosenbased on theoretical and empirical importance andinclude both time-invariant and time-varying measures.Time-invariant variables included: biological sex (male vs.female); study location (Prince George vs. Chase vs.Vancouver); education level (less than high school vs. highschool graduate or more); frequency that family had livedby traditional culture (never/rarely vs. often/always); howoften family had spoken traditional languages at home(never/rarely vs. often/always); and ability to speak owntraditional language (no vs. a little bit vs. yes). Living bytraditional culture was defined as living according tovalues that are inherent to customary Indigenous ways oflife and taught by Elders, including humility, honesty, love,respect, loyalty, remembering where you are from, andputting family first. These variables were defined by twoIndigenous Elders who are traditional knowledge keepersand members of the Cedar Project Partnership.Time-varying variables related to the previous six-monthperiod and included: age; relationship status (single vs. in arelationship); frequency of living by traditional culture(never/rarely vs. often/always; participating in traditionalceremonies (never/rarely vs. often/always); accessing alco-hol or drug treatment (no vs. yes); accessing counselling(no vs. yes); trying to quit using drugs (no vs. yes); sleepingon the streets for three or more consecutive nights (no vs.yes); frequency of crack smoking (less than daily vs. daily ormore); injection drug use (no vs. yes); binge drinking (no vs.yes); blackouts from drinking (no vs. yes); sex work involve-ment (no vs. yes); consistency of condom use with regularor casual sexual partners (always vs. not always); having asexually transmitted infection (no vs. yes); having beensexually assaulted (no vs. yes); frequency of injectingcocaine and opiates (less than daily vs. daily or more); bingeinjection drug use (no vs. yes); sharing rigs (no vs. yes);needing help to inject drugs (no vs. yes); HIV and HCVserostatus; and psychological distress. Participating intraditional ceremonies included: potlatch, feast, fast, burn-ing ceremony, washing ceremony, naming ceremony, big/smoke house, rights of passage, smudge, dances, or anyother traditional Indigenous ceremony. Binge drinking andbinge injection drug use were defined as having gone onruns or binges of drinking and injecting more than usual,respectively. Regular sexual partners were defined as part-ners with whom participants had had sexual relationshipslasting three months or more, and casual sexual partnerswere sexual relationships lasting less than three months.Sexually transmitted infections were self-reported and mayhave included chlamydia, genital warts, gonorrhoea, herpes,syphilis, or others. Psychological distress was measuredusing the Symptom Checklist-90-R (SCL-90-R) [34]. TheSCL-90-R is a 90-item self-reported symptom inventorythat measures the severity of nine dimensions of psycho-logical distress symptoms (from not at all to extremely).Participants’ SCL-90-R scores were transformed into aGlobal Severity Index, which provides an average measurefor an overall degree of psychological distress.Study participantsOf 793 participants enrolled into the Cedar Projectbetween 2003-2012, 446 completed baseline CD-RISCand SCL-90-R questionnaires. The sample was restrictedto 191 participants who had completed the CTQ andreturned for at least one additional follow-up interviewto allow longitudinal analysis. No significant differenceswere found in sex, age, childhood trauma, or meanresilience scores for participants included in this analysiscompared to those who were excluded. The overallamount of missing data for the CD-RISC items rangedfrom 0.06 % to 1.9 % of observations. A number of studyvariables also had missing data, ranging from 0.05 % to7 % of observations. The descriptive comparison be-tween means utilized list-wise deletion. The R softwarewith the lme4 package that was utilized for the LMEanalyses uses the maximum likelihood estimationmethod for random missing data within the outcomevariable (i.e. in this study, the mean CD-RISC score) anduses list-wise deletion for missing data within independ-ent variables.Statistical analysisT-tests identified significant differences in mean resili-ence scores for each dichotomous variable; robust t-testswere used when Levene’s test indicated unequal vari-ances. One-way variance analysis was used for variableswith more than two categories. Next, separate linearmixed effects (LME) models estimated the effect of eachPearce et al. BMC Public Health  (2015) 15:1095 Page 4 of 12study variable on mean change in resilience scores overthree follow-ups between 2011-2012. Bayesian Informa-tion Criteria was used to choose between fixed orrandom effect handling of study variables. Associationsbetween study variables and resilience were tested inunadjusted analyses; those significant at p < 0.1 wereincluded in multivariate models. Potential confoundersspecific to each model were chosen if they were associ-ated with the study variable and mean resilience score atp < 0.2. Potential confounders included: sexual identity,parent attended residential school, ever been in fostercare, city, relationship status, education level, and child-hood maltreatment. Sex was included in every model toaccount for gender differences. Time-varying age wasincluded in every model because of its potential import-ance as a confounder relative to the time-induced cohorteffect adjustment in this study. R statistical softwareVersion 2.15.0 with the lme4 package [35] was used [36].ResultsDescriptive statistics of demographic variables, historicaltrauma, childhood maltreatment, and resilience scores aredisplayed in Table 1. In 2011, participants’ mean age was28.9 years (SD: 5.1); 51 % (n = 97) were women. Fifty-threepercent were based in Prince George, 39 % in Vancouver,and 8 % in Chase. Nearly half (48 %) of participants had atleast one parent who had attended residential school, andmost (71 %) had been in foster care.Sixty-nine percent of participants reported having beenemotionally abused; among whom, 33 % reported severeabuse. Fifty-six percent had been physically abused,among whom 41 % reported severe abuse. Fifty-sevenpercent had been sexually abused, among whom 39 %reported severe abuse. Seventy-two percent had beenemotionally neglected, among whom 20 % reported severeneglect. Finally, 79 % had been physically neglected,among whom 39 % reported severe neglect.Reliability assessments suggested that Cedar Pro-ject data had very good fit to the hypothesizedmodel (α = 0.961). The mean resilience score was62.04 (SD: 22.2) for all participants with no signifi-cant difference between men and women. On aver-age, greater resilience scores were observed amongparticipants 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 maltreatmentwere found only for emotional neglect, with participantsreporting low/moderate or severe neglect having lowermean resilience scores than participants who reported noemotional neglect (p = 0.005).Protective factors associated with resilienceTable 2 presents results of LME models for all partici-pants. Adjusted results are presented here. Examiningthe impact of time-invariant cultural factors, having afamily who had often or always lived by traditional cul-ture was associated with higher mean resilience scores(B = 7.70, p = 0.004). Having a family who had often oralways spoken traditional languages at home was alsoassociated with higher resilience (B = 10.52, p < 0.001).Speaking traditional languages had the strongest positiveinfluence on participants’ resilience over time. Those whocurrently 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 traditionalculture in the past six months was significantly associatedwith higher resilience scores (B = 6.50, p = 0.025). In theunadjusted model, participating in traditional cere-monies in the previous six months was significantlyassociated with an increased mean resilience score.However, the association was no longer significant afteradjusting for confounders.Having accessed drug or alcohol treatment in the past sixmonths was also significantly associated with higher meanresilience scores (B = 4.84, p = 0.036). Further, although hav-ing tried to quit using drugs in the past six months wasassociated with higher resilience in the unadjusted model(B = 4.72, p = 0.092), this association was only marginallysignificant after adjusting for confounders (B = 4.98,p = 0.075).Risk factors associated with resilienceOf the five types of childhood maltreatment, only emo-tional neglect was associated with mean resilience score,with participants who had experienced severe emotionalneglect having significantly lower mean resilience scores(B = −13.33, p = 0.001).For the time-varying risk factors, having been sexu-ally assaulted had the greatest negative effect on partic-ipants’ resilience. Participants who reported sexualassault 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 fromdrinking alcohol were both significantly associated withdiminished mean resilience scores-(B = −6.19, p = 0.027).Though there was a marginal association between havinginjected drugs and lower mean resilience in unadjustedanalysis, adjusting for confounders attenuated the result.DiscussionIndigenous scholars emphasize that resilience is inherentto Indigenous cultures and that strength based in culturemakes a vital contribution to the health of Indigenouspeoples today [37]. The tenacity and strength of Indigenouspeoples has been demonstrated in 500 years of resistanceagainst colonial efforts to suppress their culture and self-determination. As this study has demonstrated, young Indi-genous people who use drugs face considerable challengesPearce et al. BMC Public Health  (2015) 15:1095 Page 5 of 12Table 1 Baseline comparisons of mean resilience scores by demographic and historical trauma variables and childhood maltreatmentexperiences among Cedar Project participants (n = 191)Baseline frequencies Resilience score p-valueN % Mean SDAll participants 191 100 % 62.04 22.22 -Demographic and historical trauma variablesAge (mean, SD) 28.89 5.07 - - -SexMale 94 49 % 64.12 22.37 0.871Female 97 51 % 60.72 23.65LocationPrince George 102 53 % 60.13 25.22 0.248Chase 15 8 % 68.93 13.53Vancouver 74 39 % 63.75 21.71Any parent attended residential schoolNo 41 22 % 63.97 21.45 0.629Unsure 57 30 % 61.12 23.27At least one parent attended 92 48 % 62.65 23.97Ever in Foster CareNo 56 29 % 68.35 19.15 0.044Yes 135 71 % 59.99 24.07EducationLess than high school 158 84 % 61.55 22.73 0.037High school or higher 31 16 % 67.83 19.21Relationship statusSingle 19 10 % 64.06 15.01 0.798In a relationship 169 90 % 62.22 23.83Childhood maltreatment severityEmotional abuseNone 57 31 % 64.13 24.27 0.503Low/Moderate 68 37 % 64.70 19.90Severe 61 33 % 58.06 25.02Physical abuseNone 81 44 % 63.65 23.34 0.894Low/Moderate 28 15 % 63.80 22.15Severe 77 41 % 60.52 23.26Sexual abuseNone 80 43 % 62.36 24.67 0.996Low/Moderate 33 18 % 62.57 24.67Severe 72 39 % 62.40 22.89Emotional neglectNone 53 29 % 69.94 20.49 0.005Low/Moderate 95 52 % 60.74 23.21Severe 36 20 % 53.08 23.41Pearce et al. BMC Public Health  (2015) 15:1095 Page 6 of 12to their resilience. A large proportion faced substantialadversities in their early lives, including having a parentwho may have struggled with the effects of residentialschool, experiencing childhood abuse and/or neglect, andhaving been in foster care. Associations between drug- andsex-related HIV and HCV risk factors and decreased resili-ence are of great concern. At the same time, it is pro-foundly reassuring that participants who had access to thebuffers of culture and language exhibited increased resili-ence. Quitting drugs and seeking help were also positivelyassociated with resilience. These findings have criticallyimportant implications for public health programming tosupport the strengths of young Indigenous people who usedrugs in Canada.Comparing resilience scores with other studiesDrawing inferences when comparing resilience scores withother samples is difficult, as resilience is dynamic andinfluenced by many intersecting factors. However, baselinemean resilience scores for Cedar Project participants weresimilar to other Canadian studies including a sample ofstreet-involved youth [38] and an ethnically diverse sam-ple of young urban people transitioning out of the childwelfare system [39].Culture and resilienceFactors that reflected familial connection to culture,including having a family who often/always lived bytraditional culture and often/always spoke their trad-itional language at home, were both very strong predic-tors of participants’ current level of resilience. Thesefindings reflect the intergenerational strength of familialcultural resources, as they provided an ongoing protect-ive effect that enhanced participants’ ability to cope withstress later in life – regardless of childhood maltreat-ment. These results are also consistent with researchthat emphasized Indigenous women’s sources of “innerstrength” (p. 87) that had originated from culturalresources within their kinship systems and with the nat-ural and spiritual worlds [40]. In addition, these findingshighlight the importance of funding health interventionsthat support Indigenous families in urban centres to con-nect to culture, languages, and spirituality, which createopportunities to nurture cultural pride and connection tocommunity in children and youth.Participants who were currently often/always living bytraditional culture had significantly higher mean resiliencescores over the study period. These findings also resonatewith previous research that measured the degree to whichliving by traditional culture provides a buffering effect onyoung Indigenous peoples’ mental and emotional health[41]. Importantly, our study demonstrates the protectiveeffect of culture and cultural identity on stress-copingability among young people who live with the complexchallenges of being street-involved, dependent on sub-stances, and facing everyday stresses of structural andinterpersonal violence. In addition, knowledge of theirtraditional language had the strongest positive effects onparticipants’ mean resilience scores. Traditional languagesare considered fundamental components of Indigenouscultures [42]. It is likely that the participants in this studywho knew how to speak their traditional language alsohad strong cultural identities and could therefore connectto the values, concepts, and beliefs that are embedded inlanguage. What is more, the enduring health benefits ofknowing their traditional language were evident regardlessof any history of historical or lifetime trauma.It is worth noting that although participating in trad-itional ceremonies in the past six months did not reachstatistical significance, the mean scores of participants whohad done so were significantly higher than the mean scoresof those who had not in the descriptive analysis. This find-ing is consistent with other studies that have found thatyoung Indigenous peoples’ participation in traditional activ-ities protects against adverse mental health outcomes andharmful ways of coping with stress, such as substance use[41]. Recent participation in traditional ceremonies mayhave lacked significance in the longitudinal analysis becauseyoung Indigenous people in cities do not have consistentaccess to traditional activities. This may be explained by thefact that most traditional protocols require abstinence forparticipation in sacred ceremonies. Our study findings sup-port calls for innovative programming to provide youngIndigenous people who use drugs with culturally acceptableopportunities to access traditional activities, languages, andteachings that promote positive stress-coping [42].This study also demonstrated a strong associationbetween having accessed alcohol or drug treatment and in-creased mean resilience scores. In addition, we found mar-ginal adjusted associations between increased resilienceTable 1 Baseline comparisons of mean resilience scores by demographic and historical trauma variables and childhood maltreatmentexperiences among Cedar Project participants (n = 191) (Continued)Physical neglectNone 39 21 % 67.47 19.11 0.580Low/Moderate 73 40 % 62.38 23.84Severe 72 39 % 59.53 24.00SD = standard deviationPearce et al. BMC Public Health  (2015) 15:1095 Page 7 of 12Table 2 Unadjusted and adjusted LME models predicting the effects of study variables on mean resilience scores among CedarProject participants (n = 191)B SE t-value 95 % CI p-value Adjusted B SE t-value 95 % CI p-valuePotential ConfoundersAge 0.29 0.27 1.05 −0.25, 0.83 0.293Female sex −2.59 2.77 −0.93 8.02, 2.85 0.353Ever in Foster Care −2.24 3.04 −0.74 −8.2-, 3.73 0.463Parents attended residential schoolNo -Unsure −4.44 3.86 −1.15 −12.02, 3.13 0.251At least one parent 1.39 3.60 0.39 −5.66, 8.44 0.700LocationPrince George -Chase 6.03 5.32 1.13 −4.41, 16.46 0.260Vancouver −2.81 2.93 −0.96 −8.55, 2.92 0.338High school education or higher 7.25 3.73 1.94 −0.06, 14.55 0.053In a relationship −7.00 4.27 −1.64 −15.37, 1.36 0.102Childhood maltreatment severityEmotional abuseNone - -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 abuseNone - -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 abuseNone - -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 neglectaNone - -Low/Moderate −5.44 3.19 −1.70 −11.69, 0.82 0.090 −5.48 3.19 −1.72 −11.73, 0.78 0.088Severe −12.96 4.01 −3.23 −20.83, −5.09 0.001 −13.34 4.04 −3.30 −21.25, −5.42 0.001Physical neglectNone - -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 connectednessFamily 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 0.004Traditional language often/always spoken athomec10.66 2.41 4.43 5.94, 15.38 <0.001 10.52 2.45 4.29 5.72, 15.33 <0.001Know how to speak traditional languagedNo - -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 0.178Yes 13.37 4.19 3.19 5.15, 21.58 0.001 13.06 4.19 3.12 4.85, 21.27 0.001Pearce et al. BMC Public Health  (2015) 15:1095 Page 8 of 12scores and having accessed counselling and having tried toquit using drugs. Because of the dynamic nature of resili-ence, seeking therapeutic help for substance use andattempting to quit drugs may be a demonstration of partici-pants’ resilience; likewise, these behaviours may help toreinforce or promote resilience. These findings are consist-ent with previous research involving Indigenous adultsliving in Edmonton, Canada, which demonstrated thathigher scores on an Indigenous enculturation scale were as-sociated with decreased illicit drug use [43]. Taken together,these results suggest that incorporating cultural teachings,values, and traditional healing within primary health careand therapeutic health services may be especially beneficialin supporting wellness among young Indigenous peoplewho use drugs. Indeed, such wellness-focused interventionsmay facilitate healing from the effects of intergenerationaltrauma, and support resilience against experiences of struc-tural and interpersonal violence. Compared to public healthefforts that focus solely on addressing risk factors, interven-tions that cultivate cultural resilience may also reduce orprevent young Indigenous people’s susceptibility to HIVand HCV exposure within high-risk environments.Challenges to resilienceIt is deeply concerning that 92 % of participants in thisstudy had experienced some type of maltreatment (datanot shown) and that high proportions experiencedsevere maltreatment. However, only emotional neglectwas significantly associated with decreased mean resili-ence scores. Emotional neglect is often characterized byacts of omission by caregivers who persistently deprivechildren of basic psychological and emotional nurturing,encouragement, and feelings of belonging [44]. Effects ofchildhood emotional neglect can extend into adulthoodand increase the likelihood that adults will experiencediminished cognitive, social, and emotional functioning,and most notably, have difficulties with positive adaptationand stress-coping [44, 45]. Recently, the Truth and Recon-ciliation Commission of Canada described the egregiousnegligence of generations of Indigenous children in resi-dential schools as “institutionalized child neglect” [46].Residential school survivors have recalled feeling isolated,deprived of love, nurturing, or comfort, and being instilledwith a sense of worthlessness. This approach was highlydissimilar to traditional parenting styles and impactedTable 2 Unadjusted and adjusted LME models predicting the effects of study variables on mean resilience scores among CedarProject participants (n = 191) (Continued)Often/always lived by traditional culture inpast six monthse7.15 2.76 2.59 1.74, 12.55 0.010 6.50 2.88 2.26 0.86, 12.14 0.025Participated 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 0.199Other protective factors in the past six monthsAccessed 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 0.036Accessed any counsellingh 3.86 2.38 1.62 −0.80, 8.52 0.105 4.21 2.38 1.77 −0.46, 8.89 0.079Tried quitting drugsi 4.72 2.79 1.69 −0.75, 10.19 0.092 4.98 2.85 1.75 −0.60, 10.57 0.075Risk factors in the past six monthsSlept 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 0.044Injected drugsk −4.41 2.65 −1.66 −9.60, 0.79 0.098 −4.12 2.75 −1.50 −9.50, 1.27 0.136Sex 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 withregular partners4.48 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 0.041Blackouts from drinkingm −5.75 2.65 −2.17 −10.97, −0.56 0.032 −6.19 2.77 −2.23 −11.62, −0.75 0.027Binge 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 0.333SD = standard deviationa,d,h,lAdjusted model included confounders age and sexb,j,mAdjusted model included confounders age, sex, education level, and childhood emotional neglectc,e,kAdjusted model included confounders age, sex, and emotional neglectf,gAdjusted model included confounders age, sex, education level, relationship status, and emotional neglectiAdjusted model included confounders age, sex, education level, and having ever been in foster carePearce et al. BMC Public Health  (2015) 15:1095 Page 9 of 12survivors’ own parenting. Consequent intergenerationaltrauma may be affecting young Indigenous people todaywho turn to drugs and alcohol in the absence of safeand effective coping mechanisms. Mental and publichealth interventions serving young Indigenous peoplewho use drugs must be cognizant of possible intergener-ational impacts of emotional neglect and its specificeffect on resilience.Descriptive findings in this study demonstrated thatparticipants who had been in foster care had signifi-cantly lower mean resilience scores than participantswho had not. Despite not retaining significance inadjusted models, this finding merits attention as Indigen-ous leaders have called for an end to the cycle of childapprehension through long-term, culturally-relevant re-sources to support young people to heal and recover theresilience innate to their cultures and ways of knowing [7].Future research must involve young Indigenous peoplewho use drugs and who have experienced the child wel-fare system to identify how to support healthy attach-ments to their families and cultures [47].Sexual assault had the strongest negative associationwith participants’ mean resilience scores in this study.This finding is concerning, as approximately half of thosewho experience sexual assault develop post-traumatic stressdisorder symptoms if unable to access timely interventionsthat facilitate positive stress-coping and adaptation [48].Survivors of sexual assault who suffer from post-traumaticstress disorder are more likely to self-blame and engage inharmful coping strategies such as heavy alcohol and druguse, thereby increasing their vulnerability for HIV andHCV infection [49]. Previous research has highlighted therelationship between intergenerational trauma caused bythe residential school system and sexual violence experi-enced by young Indigenous women who use drugs [14].Sexual assault prevention and intervention strategies foryoung Indigenous people who use drugs must therefore betrauma-informed and specifically tailored to establish trust-based relationships within culturally-safe settings.Smoking crack daily and blackout drinking were alsoindependently associated with decreased mean resiliencescores. Few studies have explored the association be-tween resilience and problematic substance use amongvulnerable populations [38, 50]. However, research hassuggested that poor mental health–especially depressionand post–traumatic stress disorder–precedes heavy alco-hol consumption and cocaine use (rather than viceversa) [51, 52]. These findings may be interpreted as in-dicating that young Indigenous people use drugs to copewith stress because of a lack of alternative coping skillsor access to culturally-relevant mental health and ad-diction resources within urban centres. This potential-ity is deeply concerning given that HIV risk andinfection has been linked with unsafe sex practices thatoften coincide with heavy alcohol consumption andcrack smoking [53, 54].There are several important limitations to this study.First, it utilizes self-reported behavioural data obtainedfrom a non-probabilistic sample. Although we cannotrule out selection bias, we are confident that our recruit-ment methods and rigorous eligibility criteria ensuredthat our sample is representative of Indigenous youngpeople who use drugs in Vancouver, Prince George, andChase. There was potential for recall bias, socially desir-able reporting, and misclassification of exposures (exceptfor HIV/HCV serostatus) and the outcome variable.Additionally, we cannot draw conclusions regarding thecausality between the time-varying study variables andresilience. We also acknowledge that the CD-RISC isbased on Eurocentric concepts and is likely unable tocapture some of the deeper sociocultural and ecologicalfactors that contribute to the resilience of Cedar Projectparticipants [25].ConclusionsIn conclusion, this study has demonstrated what manyIndigenous scholars and Elders have known for genera-tions: that cultural teachings, values, and languages arethe foundations of resilience among Indigenous peo-ples. In the aftermath of colonization, these founda-tions continue to function as “cultural buffers” [55]that protect Indigenous peoples from severe health out-comes, including HIV and HCV infection. The youngIndigenous people in this study are survivors, as theyhave adapted to and lived through multiple and inter-secting adversities. This study has demonstrated thatthose young people who had access to culture andlanguages were buffered both psychologically andemotionally. Conversely, this study underscored theimportance of culturally-safe and trauma-informed in-terventions that prevent any further decline in thestrength of young people–especially those who haveexperienced sexual violence and those using alcoholand drugs very heavily. Supporting the reconstructionof cultural identities among young Indigenous peopleliving in urban centres who are either disconnectedfrom their cultures or have never experienced their cul-tures may be challenging [26, 27]. Young Indigenouspeople who use drugs must be involved in the design,implementation, and evaluation of any programs or re-sources that intend to support cultural identity, culturalpride, and cultural resilience.AbbreviationsBC: British Columbia; CTQ: Childhood Trauma Questionnaire; CD-RISC: ConnorDavidson Resilience Scale; HCV: Hepatitis C virus; HIV: Human ImmunodeficiencyVirus; SCL-90-R: Symptom Checklist 90-Revised.Competing interestsThe authors declare that they have no competing interests.Pearce et al. BMC Public Health  (2015) 15:1095 Page 10 of 12Authors’ contributionsMEP was responsible for the conception of the research question, statisticalanalysis, interpretation, and drafted the manuscript. KJ made significantcontributions to the data interpretation and drafting of the work. CR madeintellectual contributions to the content of the paper and interpretation ofthe data. EWH and SP made significant intellectual contributions to theinterpretation of the analysis and drafting of the work in addition toproviding cultural guidance. EOJ made intellectual contributions to thecontent of the paper and interpretation of the data. WC contributed to thedata analysis and the draft of the work. MTS and PMS made essentialcontributions to the analysis and interpretation of the study and madecritically important contributions to the intellectual content. Each authorgave their final approval to this version of the manuscript to be published.Author’s informationMEP recently completed her PhD at the University of British Columbia (UBC)School of Population and Public Health (SPPH); KJ is a PhD candidate atUBC-SPPH and a trainee with the Centre for Health Evaluation and OutcomeSciences (CHEOS); CR is an Associate Professor at UBC-SPPH and a ResearchScientist with CHEOS; EWH has Cree and Métis Ancestry, is an Elder andKnowledge Keeper, and an Adjunct Professor at the University of NorthernBritish Columbia; SP is Cree, a Research Manager at the Canadian AboriginalAIDS Network, and a Sessional Instructor at the University of Victoria in BritishColumbia; EOJ is an Associate Professor at UBC-SPPH and Research Scientistat CHEOS; WMC is from Splatsin Secwepemc Nation and is the electedKukpi7 (Chief) of his community; MTS is the Chief Scientific Officer at theMichael Smith Foundation for Health Research and a Professor at UBC-SPPH; PMSis the Interim Associate Director of Research at the UBC Centre for Excellence inIndigenous Health, a Professor at UBC-SPPH, and a Research Scientist at CHEOS.AcknowledgementsWe are indebted to the study participants for their participation in the CedarProject. Special thanks are due to the Cedar Project Partnership for theirconviction and for holding us accountable to the voices of young Indigenouspeople. To the Elders who support our study, particularly Violet Bozoki and EarlHenderson, 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 bethanked for their conviction and contributions. The Cedar Project receivesongoing 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; CarrierSekani Family Services; Positive Living North; Prince George Native FriendshipCentre; Red Road HIV/AIDS Network; All Nations Hope; Splatsin SecwepemcNation; Neskonlith Indian Band; Adams Lake Indian Band.Author details1School of Population and Public Health, University of British Columbia,Columbia, Canada. 2Centre for Health Evaluation and Outcome Sciences,588-1081 Burrard St., V6Z1Y6 Vancouver, BC, Canada. 3Cree, Métis; Universityof Northern British Columbia, Columbia, Canada. 4Cree; University of Victoria;Canadian Aboriginal AIDS Network, Victoria, Canada. 5Splatsin te SecwepemcFirst Nation, Columbia, Canada.Received: 2 July 2015 Accepted: 12 October 2015References1. Dion-Stout M, Kipling G, Stout R. 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