Exploring American Indians Knowledge, Attitudes, Beliefs, and Behaviors Surrounding the COVID-19 Pandemic

By Caitlin Haas

I began working for the Institute for Indigenous Studies (IIS) at Lehigh University in the summer of 2021. For the majority of that time, I was a part-time research assistant while I was completing my degrees in Psychology and Behavioral Neuroscience. Upon my graduation, in the fall of 2022, I transitioned to be a full-time research associate. The IIS is housed within Lehigh University’s College of Health and headed by Drs. Christine Makosky Daley and Sean M. Daley. The IIS seeks to alleviate health disparities in Indigenous populations through education and research. Two of our current lines of inquiry are tobacco cessation and the impact of the COVID-19 pandemic on American Indians/Alaska Natives (AI/AN). 

Significant health disparities existed for this population before the pandemic, including  inadequate and discriminatory healthcare systems and extreme poverty rates (Center for Disease Control, 2020; Humeyestewa et al., 2021). Additionally, AI/AN on average suffer from higher prevalence of preventable illnesses such as cardiovascular disease, diabetes, chronic lower respiratory diseases, which in turn increased the risk of contracting COVID-19. In 2020, it was reported by the Center for Disease Control that Native Americans had 3.5 times more COVID-19 cases, were 4 times more likely to be hospitalized, and 3.5 times more likely to die than non-Hispanic whites (CDC, 2020). To further emphasize this point, AI/AN life expectancy dropped by 4.5 years from 71.8 to 67.3 years of life in 2020 (Goldman and Andrasfay, 2022). This was the sharpest decline of any racial, ethnic, or political group (Goldman and Andrasfay, 2022).

In addition to the high mortality rate, other factors contributed to the unique experience of Indigenous peoples during the pandemic. COVID-19 deaths were particularly devastating for Native communities because they often rely on elders for the continuity of spiritual and cultural traditions. The loss of these elder community members jeopardizes the passing down of traditional cultural knowledge. Additionally, AI/AN are already distrustful of the federal government because of past governmental traumas. Leadership impacted the AI/AN perception of pandemic in a way unique to other racial, ethnic, and political groups. Because of the status of federally-recognized tribes as sovereign nations, many Native people were witness to policies shaped by leaders on the federal, state, and tribal levels as citizens of both their tribe and the United States (Boyd and Buchwald, 2021).

When I started working on our Knowledge, Attitudes, Beliefs, and Behaviors (KABB) project in the summer of 2021, collection of both qualitative and quantitative data was already underway. This was my first foray into the world of mixed methods and community-based participatory research. The goal was to understand how the history of Native peoples, past experiences with the federal government, and maintaining Native identities shaped AI/AN knowledge, attitudes, beliefs, and behaviors surrounding the COVID pandemic.

In total, we collected almost 400 KABB surveys from Native participants around the country. I contributed to the data entry and cleaning process. I first audited the surveys to try and reduce discrepancies between primary and secondary data entry into RedCap©. Along with several other IIS interns, I then helped with data entry, itself. During this process, I was in charge of managing the data and making sure all the paper surveys were in both primary and secondary databases. Upon completion of data entry, my colleague ran compares, and I cleaned the data so that the primary and secondary data bases matched. I learned a lot from this aspect of the project; before this, I had never worked with RedCap© and am now proficient in it. We are currently in the process of analyzing the survey data, and I’m excited to review the results of this analysis. 

On the qualitative side, I began by transcribing numerous interviews conducted by more senior members of our team. Participants were screened into our semi-structured interviews via both snowball sampling and by answers to questions on our KABB survey that were different from predominantly held perspectives on the virus. These questions dealt with topics such as the severity of the virus, the vaccine, and the efficacy of traditional knowledge and ceremony against illness. We sampled from many different geographic regions across the United States. As a budding psychologist, it was fascinating to hear how differently people experienced the pandemic based on their location and how their experiences informed their worldviews. The interview questions themselves inquired after participants’ reactions to the virus, perceptions of leadership across different levels, adherence to restrictions, feelings about the general public’s response, and preliminary thoughts surrounding COVID vaccines.

Upon the conclusion of qualitative data collection, I was part of a team of three coders - two etic and one emic - who developed a codebook. We then coded and organized the data into pre-themes. Each coder developed pre-themes individually, and together, we determined saturation via group discussion. Eleven themes emerged from our analysis. These centered around three categories: opinions on leadership responses throughout the pandemic on the federal, state, and tribal level; interaction between leaders’ and community values on personal responses; importance of tending to the needs of elders and preserving cultural heritage. The individual themes are shown in Figure 1.

Figure 1. Resulting themes from our KABB interviews

Throughout the course of the pandemic, the already existing health disparities faced by AI/AN communities were exacerbated; many communities experienced devastating loss of life. Conflicting policies and perceived mismanagement of the pandemic intensified issues of mistrust between Indigenous people and both the federal government and the medical community. Many people saw the federal government as ineffective at containing the pandemic and attributed these issues to the pandemic’s politicization. They saw leaders on the state and federal levels as largely taking an individualistic approach, which did not resonate with many of them.

On the other hand, participants perceived tribal leaders as excelling during the pandemic. People generally felt their tribal governments prioritized the wellbeing of people rather than the economy and appreciated the restrictions tribal governments put in place. Though at times these restrictions were even more stringent than those of the CDC, participants abided by these policies on the whole. For some, compliance was contingent upon reckoning with previous historical trauma; pandemic restriction policies often mirrored prior federal policies aimed at assimilating AI/AN people and eradicating their culture.

Drs. Christine and Sean Daley have provided me with ample opportunities in terms of dissemination of this work. We are working on several papers based on data from this project, which I have helped author. Additionally, I had the chance to present the results of the qualitative analysis part of the project detailed here at the 23rd Annual SfAA Meeting in Cincinnati in March. It was my first conference experience, and I was first author on this presentation, featured in the Parades Plenary Session. I am grateful to Drs. Christine and Sean Daley, as well as SfAA, for the opportunity.

Works Cited:

Boyd AD, Buchwald D. Factors That Influence Risk Perceptions and Successful COVID-19 Vaccination Communication Campaigns With American Indians. Sci Commun. Feb 2022;44(1):130-139.

Center for Disease Control and Prevention (2020, August 19). “CDC Data Show Disproportionate COVID-19 Impact in American Indian/Alaska Native Populations.” https://www.cdc.gov/media/releases/ 2020/ p0819-covid-19-impact-american-indian-alaska-native.html

Goldman, N. & Andrasfay, T. (2022). Life Expectancy Loss among Native Americans During the COVID-19 Pandemic. Demographic Research 47 (9), 233-246.

Humeyestewa D, Burke RM, Kaur H, et al. COVID-19 response by the Hopi Tribe: impact of systems improvement during the first wave on the second wave of the pandemic. BMJ Glob Health. May 2021;6(5).