Wellbeing of Indigenous Peoples in Canada, Aotearoa (New Zealand) and the United States: A Systematic Review

Despite the health improvements afforded to non-Indigenous peoples in Canada, Aotearoa (New Zealand) and the United States, the Indigenous peoples in these countries continue to endure disproportionately high rates of mortality and morbidity. Indigenous peoples’ concepts and understanding of health and wellbeing are holistic; however, due to their diverse social, political, cultural, environmental and economic contexts within and across countries, wellbeing is not experienced uniformly across all Indigenous populations. We aim to identify aspects of wellbeing important to the Indigenous people in Canada, Aotearoa and the United States. We searched CINAHL, Embase, PsycINFO and PubMed databases for papers that included key Indigenous and wellbeing search terms from database inception to April 2020. Papers that included a focus on Indigenous adults residing in Canada, Aotearoa and the United States, and that included empirical qualitative data that described at least one aspect of wellbeing were eligible. Data were analysed using the stages of thematic development recommended by Thomas and Harden for thematic synthesis of qualitative research. Our search resulted in 2669 papers being screened for eligibility. Following full-text screening, 100 papers were deemed eligible for inclusion (Aotearoa (New Zealand) n = 16, Canada n = 43, United States n = 41). Themes varied across countries; however, identity, connection, balance and self-determination were common aspects of wellbeing. Having this broader understanding of wellbeing across these cultures can inform decisions made about public health actions and resources.


Introduction
Canada, Aotearoa (New Zealand) and the United States are all highly developed countries [1], yet the benefits of their development are not shared equally across all members of these societies. Disparities experienced by Indigenous people are underpinned by the unequal distribution of social, political and economic determinants of health and wellbeing [2]. Indigenous peoples' personal and collective experiences of disempowerment, marginalisation, loss of land, and racism have adversely impacted their health and wellbeing [1,[3][4][5]. These factors are exacerbated by institutional systems, including health Box 1. Butler et al., 2019. Domains of wellbeing for Indigenous Australians [11].
(1) Autonomy, empowerment, and recognition; which influences wellbeing through agency and self-determination of the individual and community; (2) Family and community; including kinships and notions of social and cultural connectedness; (3) Culture, spirituality and identity; which is interrelated and multidirectional; (4) Country; which is a holisticconcept encompassing identity, spirituality, culture, peoples, language, law and ceremony; (5) Basic needs; including food, money, housing and access to services; (6) Work, roles and responsibilities; both paid employment to meet basic needs and roles within community (including employment with Indigenous led companies); (7) Education; which presented as a complex relationship where tensions were felt between the need for formal schooling, and desire to pass on and learn cultural knowledge, and; (8&9) Physical health and Mental health (two separate themes); both encompassed a holistic understanding of health that is complex and culturally-bound.

Materials and Methods
The current review was led by an Indigenous researcher from Australia (AG), with guidance from senior Indigenous researchers from Australia (GG), Canada (AK), Aotearoa (New Zealand) (EW) and the United States (MC). This review is part of a larger body of work that aims to develop a new instrument to measure wellbeing for Aboriginal and Torres Strait Islander adults, in order to more effectively inform decision making As shown in Figure 1, a total of 4218 papers were identified in the search, with a further six papers identified through hand-searching the reference lists of included papers and relevant earlier review papers (n = 6). An additional paper known to the authors but not indexed in the included databases at the time of the search was also included (n = 1). After removing duplicates (n = 1556), the titles, abstracts, and keywords of 2669 studies were screened against the inclusion criteria using Rayyan online software for systematic reviews [13].  AG and KA independently double-screened, all 198 papers and deemed 100 papers eligible for inclusion in the review. The final 100 included papers were imported into NVivo 12 qualitative data analysis software [14] for data extraction and analysis (see Figure 1). Main reasons for exclusion included: population not relevant (n = 1439), disease-specific focus (n = 318), wrong publication type (n = 297), wrong study design (n = 273), and nil wellbeing focus (n = 196) (see Appendix A).

Data Extraction and Analysis
The following characteristics were extracted from all the included papers by DL then checked by AG for accuracy: publication information (authors, year of publication, paper title, country, region, aim/research question, whether wellbeing was part of the main study aim or broader research question, data collection method, qualitative method, and study setting), and participant information (eligibility, total number of participants, Indigenous group(s) included, and age and sex distribution).
Aspects of wellbeing were extracted using NVivo 12 [14] by AG using the three stages of thematic development recommended by Thomas and Harden for thematic synthesis of qualitative research [15]. Themes were defined as any aspect described in the paper as important to the wellbeing of Indigenous people in Canada, Aotearoa (New Zealand) and the United States. AG extracted the themes for each country separately; analyses were also conducted separately for each country. The data were coded by AG 'line-by-line' and then developed into 'descriptive themes' that were checked by KA and GG for accuracy and coverage of coding and theme development. The third stage recommended by Thomas and Harden [15] was adapted; Indigenous co-authors from Aotearoa (New Zealand) (EW), Canada (AK), and the United States (MC) were invited to review their respective country's results to ensure correct interpretation and reporting of the data.

Results
Across Canada, Aotearoa (New Zealand) and the United States, different words are used in the included papers to describe wellbeing such as wellness and well-being, as well as specific Indigenous language words. How these words are chosen and defined by each Indigenous group is critically important. However, to aid the reader throughout this review, we will respectfully use the word wellbeing, as the majority of the included papers across the three countries used this as their primary terminology to describe Indigenous peoples' wellbeing.

Paper Characteristics
Of the 100 papers included in our review, 43 were from Canada, 16 were from Aotearoa (New Zealand) and 41 were from the United States (see Supplementary Materials Table S1). In brief, the vast majority of papers were solely qualitative studies (n = 91); collected data via face-to-face interviews (n = 80); and recruited participants via the community, often with the assistance of a community contact (n = 61). Wellbeing was part of the main research aim in 52 papers, with 48 including this as a component of the broader research question.
Most of the papers included only an Indigenous sample (n = 72), 10 included a mixed sample of Indigenous and non-Indigenous participants, and in a further 18 papers, it was unclear if the sample was solely Indigenous or may have included some non-Indigenous peoples. Of those where the sample included both Indigenous and non-Indigenous peoples, we only included the views of those who could be identified as Indigenous. Throughout the results, we have incorporated the country-specific terminology used in the included papers to refer to the Indigenous peoples of their respective countries.

Thematic Synthesis Results
Our team chose to analyse the existing evidence around the wellbeing of Indigenous peoples both within and between the three countries included in this review. While our decision in this regard was guided by practical considerations, we wish to acknowledge that the boundaries of contemporary nation states do not always align with those of Indigenous nations, tribes and groups. To account for the complexities associated with these circumstances, we have also looked at the similarities in wellbeing between countries, which may in part be driven by some of these inconsistencies between Indigenous cultural groups and Western borders.

Canada
Forty-three  papers came from Canada; 'Indigenous peoples in Canada' is used to collectively report on the aspects of wellbeing as reported in the included papers for First Nations, Métis and Inuit [59].
"In the four components, I try to keep a balance . . . I think of the four areas, emotional, physical, spiritual and mental." [36] Several papers emphasised this connection in terms of the individuals being connected with the land and each other [16,19,30,32,[35][36][37]42,45,49,52,56]. The quality of each of these complex connections was said to be central in achieving wellbeing.
Elders and grandparents said that healing occurs when cultural knowledge that is important to identity is passed down [53]. Identity was derived through connection with land and culture and having a role in family and community [36,49,51,58].
" . . . understanding who I am, who I am in terms of my family, my parents and my siblings, uncles, aunts and where I fit in the community, my relationships, aunts, uncles and all of that." [36] The impact of removal from one's community and family was reported as negatively influencing some peoples wellbeing. In some papers, it was reported that those adopted or taken into foster care are reconnecting with their cultural identity [19,38,49,53].
"It's hard because we were raised white . . . But you know, I'm okay and I'm slowly learning more things about who I am-the connections and the boundaries." [53] Language The importance of one's Indigenous language, learning and knowing it, was reported by twelve papers [19,22,27,29,33,36,38,40,45,49,53,54]. Language was reported as fundamentally connected to culture, and language was regarded an important means for passing on, preserving and continuing culture, while also bringing a sense of pride, confidence and improved family, community and spiritual connections for the Indigenous peoples in Canada [19,22,28,29,38,40,45,49,[53][54][55]. This is not to exclude those without access to language, as culture can and is passed down without it.
" . . . talking to one or more others was essential to one's well-being . . . talking was identified as the significant component of prevention, intervention, and healing." [35] Opportunities to be social and attend social engagements was reported as important to wellbeing; being able to connect with community during community events, regular group gatherings, performing cultural activities and sharing meals/resources were all seen to reduce issues associated with isolation and, in turn, build strong relationships [19,22,25,29,31,36,43,46,47]. Where these connections were lacking, either due to distances apart or climate change reducing access to land, participants spoke of a desire to connect to improve wellbeing [23,24,28,31,37,43].
" . . . as a marginalized people, [we] have a very big void to address in that area . . .
[people] may not even know they belong to a community. And when you're isolated like that we all tend to go to the dark side so to speak. A healthy community is a strong community." [19] Supporting other community members was reported as important to Indigenous peoples in Canada [20,22,24,25,[28][29][30]35,36,39,41,45,51,53]. Some participants spoke about needing the support of others [25,30,41], and how providing support boosts wellbeing [22,30,36], while others explained that caring for others can impact wellbeing in complex ways (both in a positive and negative way) [20,28].
" . . . looking after children . . . many of those children are now adults who come to me to tell me I was good to them while they were young. It feels really good inside to know that they have not forgotten me. It's a rewarding feeling." [22] An important way that the Indigenous peoples in Canada support each other and improve the wellbeing of the whole community is through the sharing of resources, especially food [24,25,28,29,35,36,39,45]. This highlights the importance of food quality, food security and food sovereignty to the wellbeing of the Indigenous peoples in Canada (these considerations also relate to the Land and Sea, and the Physical, Mental and Emotional Wellbeing themes).
"The meat was divided accordingly, nobody was left behind. The men would be up all night carving the meat, and people would come by to pick up their share . . . The people . . . were looking after the community." [24] Some papers reported that the wellbeing of the entire community required cohesion and self-determination, with strong leadership, guidance and teaching from Elders, and collective decision making that prioritised the needs of the community [17,[27][28][29]31,35,36,39,45,48,51,54,55,57].
"Home is living in a [healthy] community where there are elders to undertake (Indigenous) teachings in sharing circles and different ceremonies. This is what makes us who we are. We get our self-identity through communal living and the teachings that go on in the communities." [17] 8 of 31 Family was reported by 20 papers as important to the wellbeing of Indigenous peoples in Canada [17,18,22,23,[27][28][29][30][35][36][37]39,42,43,45,47,49,[53][54][55], particularly family connection, Elders holding and sharing cultural knowledge within the family and the importance of passing this down through the generations. Connecting with family brought a sense of pride, belonging and security [22,30,35,39,43,53], which, when lost, had a negative impact on wellbeing [17,35,36]. The binding together of families through these connections was often enacted through the family participating in cultural activities together [28,35,39,42,43,47,53].
"[Family] provided acceptance and a sense of belonging, pride and respect . . . provid[ing] them with hope, knowing that they can always turn to a family member or friends for support." [30] " . . . culture [is] essential for family well-being . . . [culture] 'bound individuals together' via sharing food, sharing language, hearing Elders' stories and going out on the land." [28] The concept of family for Indigenous peoples in Canada is broader than nuclear family structures. For Indigenous peoples, it extends to distant relatives, friends and chosen family (i.e., non-blood-related people they consider family), which provides an individual with a large and diverse support network, and, in turn, fosters and strengthens wellbeing [17,39,47,49].
"But the times have changed a lot and the young people are now in a place where they don't really know the old traditional ways but they know the new way more . . . And it's due to the fact that the elder's voices are starting to, you know, diminish . . . I want the young people to know that. Elders are an important part of their life." [35] Land and Sea Land and sea was reported by 27 papers as "vital" to the wellbeing of the Indigenous peoples in Canada [16,[24][25][26][27][28]31,32,[35][36][37]39,40,[42][43][44][45][46][47][48][49][50][52][53][54]56,57]. The importance of land, encompassing land, sky, sea and animals, is culturally embedded; the land "is in their bones and in their blood [31]".
"The respect that we need to show the land and its relatedness to us. We are the land. If the land is sick then it ain't going to be very long before we're going to get sick." [54] The importance of this reciprocity, in the sense of the land being a teacher and the importance of passing on cultural knowledge through the generations, was reported in several papers [24,28,32,35,39,44,46,50,54]. The sense that the teachings of the land have not been lost, but rather need to be reawakened and learnt again, was evident throughout.
"These rapid [climate] changes were described as disrupting hunting, fishing, foraging, trapping, and traveling to cabins because people were unable to travel regularly (or at all) due to dangerous travel conditions and unpredictable weather patterns." [26] Resilience Stories of resilience were cited by 21 papers as important to the wellbeing of the Indigenous peoples in Canada, due to the effects of colonisation and how, through resilience, they have been able to protect collective history, culture and build the strength of the community [16,19,[22][23][24]28,29,33,35,36,38,41,42,45,[48][49][50][53][54][55]57]. Resilience is culturally grounded, including: " . . . culturally distinctive concepts of the person, the importance of collective history, the richness of Aboriginal languages and traditions, and the importance of individual and collective agency and activism" (p. 88 [61]) "Although, there were clear power imbalances, the elders still perceived Aboriginal people to have some agency and power over their existence and cultural practices, resisting the encroaching European and 'White' dominance." [33] Resilience was especially evident in the papers that spoke about residential schools and the lasting impact that these negative experiences had on wellbeing [22,24,29,33,36,38,53,54].
" . . . I dealt with all those hard emotional issues and began to build my life as someone with self-esteem . . . I eventually settled into who I was, my culture, and learned about residential schools and started a path of forgiveness for those that had harmed me." [38] Resilience was seen in acts of resistance to the rules imposed by residential schools, local authorities and the Church. Such rules were aimed at preventing the Indigenous peoples in Canada from engaging in spiritual and cultural practices [33,53,54], which had severe and ongoing impacts on wellbeing [33,42,50,53,54,57]. Those who defied the rules found this enabled them to hold onto their identity, culture and connections, which was important for rebuilding wellbeing later in life.
"They'd all take their bundles; their sacred items and they'd go up the river. Way up the river in the secret that's where they'd do their ceremonies. They would never, ever do it in the community because it was against the law. You went to jail if you were caught doing those things." [54] Resilience was demonstrated in a number of ways, including the demand for culturally safe services [19,22,23,28,49], and enacting autonomy in the face of pervasive racism and stigma [16,[22][23][24]29,38,41,45,49]. The Indigenous peoples in Canada enacted resilience through stories of resistance and activism [16,29,33,38,41,48,50,54]. Resistance and, ultimately, the regaining of self-determination were seen as fundamental to the wellbeing of the whole community [42]. Learning to navigate through "two worlds "(Indigenous/cultural and colonised/Christianised) was reported as important to wellbeing [33,35,36,53,55,57].
" . . . [we] try to balance those two worlds . . . And those [cultural] teachings have to come back in order to know who we are and how to balance ourselves." [36] Resistance against negative stereotypes and stories about the Indigenous peoples in Canada was said to be central in changing others' perceptions of them, as well as for the identity and wellbeing of the Indigenous peoples in Canada themselves.
"I really believe it's important that our [Aboriginal peoples] story is accurately portrayed. New people to this country, as well as most Canadian citizens, need to know our story, need to understand the impacts of colonization and the residential school system on our cultures, history and languages, and the future impacts these will have for generations to come." [22] Spirituality and Cultural Medicine The Indigenous peoples in Canada's spirituality and cultural medicine were reported by 18 papers as important to wellbeing [17][18][19][20][21][22]30,[32][33][34]36,42,45,46,53,54,56,58].
"One way to get in tune with the earth is to go to a sweat lodge . . . You go into the sweat praying and sweating. It is a cleansing and the whole time you are in there, you are praying . . . You feel so good when you come out of there." [56] Spirituality improved one's mental health and gave a sense of place, through important connections to those who have passed and who's presence is still felt today [22,36].
"Land-based, cultural activities are an important component of physical activity . . . ." [31] " . . . traditional foods are a lot healthier than the majority of store-bought foods, but due to circumstances such as the changing environment and decreasing numbers of traditional animals, a lot of community members are consuming more store-bought foods." [52] For older people and those with disabilities, having access to culturally safe services and welcoming places to rest while using these services was seen as important to wellbeing [22,23,42].
The First Nations older adults also felt that accessibility played a significant role in their ability to age well (safe, accessible, flexible, and affordable transportation in the city). This was particularly the case for the participants who identified as having a disability(ies)." [23] Mental and emotional wellbeing was reported as important to the overall wellbeing of the Indigenous peoples in Canada in 19 papers [17,[19][20][21]26,[29][30][31][32][33]36,38,47,49,51,53,54,56,58]. Understandings of mental and emotional wellbeing were intertwined with the Medicine Wheel, where all aspects of the wheel need to be in balance in order to achieve and maintain mental and emotional wellbeing [19,49,51,58]. Connecting to culture was seen as critical to maintaining mental and emotional wellbeing, including connecting spiritually and to the land [26,[30][31][32]36,47,49,51,54,56].
"So mental health isn't just mental health, it's spiritual health, physical health and emotional health as well." [19] Relationships with family and the community, including supporting each other, were seen as important to maintaining and building healthy mental and emotional wellbeing [19,30,36,47,49,51].
"mental health and well-being is not a new concept. However, given the history of colonization and especially the residential school legacy, it is essential to understand the increased significance of relationships on contemporary Indigenous peoples' mental health and well-being." [30] Trauma was a recurring theme, especially associated with residential schools and abuse, manifesting intergenerationally, as pain was passed down through the generations [19,[29][30][31]36,38,49,53]. "Dealing" with the trauma and talking through their pain and their emotions were seen as means to regain wellbeing [19][20][21]51,58].
"You can deal with intergenerational trauma as well by acknowledging it, realizing it, respecting it, learning from it, forgiving it . . . the biggest gift I ever gave myself, was really doing that hard trauma work." [19] Maintaining mental wellbeing required being actively employed and not being idle [20,21,36,47].

Māoritanga-Identity
Māoritanga was cited by nine papers as having a central role in Māori wellbeing [64,66,[69][70][71][72]74,75,77]. It can be translated as meaning identity, as it encompasses Māori culture, practices and beliefs [78]. This broad reaching concept was described, not only as a vital component of wellbeing, but also as an overarching concept that connected and united other aspects of life that emerged as important to Māori wellbeing. Māoritanga is cultivated and strengthened through connections with Māori culture, Māori language, connections to the land and whānau (family).
"A collectivist approach to the men's sense of self is lived through connections with whanau." [64] Culture is an important 'living' factor to Māoritanga, both for the individual and the collective [66,71,72,77]. One paper identified the importance of learning Māori language to Māori women in reclaiming cultural identity [72]. Participating in cultural activities, such as Kapa Haka (Māori singing and dancing), was described as adding to Māoritanga of Māori as a collective [72]. This was also true of Māori responsibility to attend sites of significance to the iwi (tribe) [70]. These aspects of participating in Māori culture and fostering Māoritanga were put forward as the basis for building wellbeing among Māori people.
"Māori identity and culture includes obligations and responsibilities to attend activities and sites connected not only to their tribe, but also their family identity." [70] Māoritanga also incorporates Māori connection to the land and guardianship of it [69,70]. The central importance of land to Māori wellbeing was illustrated by the Māori custom of using geographical land features such as maunga (mountains), awa (rivers) and moana (oceans) to identify themselves as individuals within the collectives of the hapu (sub-tribe) and iwi (tribe) [69].
"Māori identity is linked to the earth by a sense of belonging to the land, being part of the land and being bonded together with the land." [69] The forced assimilation of Māori when Pākehā (Europeans) came to Aotearoa (New Zealand) was seen as a source of conflict [71]. Reconciliation was described as fraught and the act of forgiveness for the past was described as involving further damage to Māoritanga [71].
Pūrakau (ancient story or legend) and whakatauki (proverb) Pūrakau and whakatauki were reported in five papers as important to the wellbeing of Māori [62,65,67,69,74]. Pūrakau and whakatauki are the narrative tools with which Māori pass down cultural wisdom and knowledge [78]. A sense of pride was associated with passing down knowledge through the generations [62,65,67,74] as was instilling pride in others, creating connections between people through sharing and knowing family history [62,65,67,74]. Both the content of these stories and proverbs and also, the act of sharing them and passing down this knowledge, are intrinsic to Māori culture and maintain a strong connection to the land [65,69]. The sharing of knowledge in this way was described as locating Māori, giving a sense of place and identity for Māori now and future generations.
"One of Winiata's aspirations is to ensure he passes on his practical skills and knowledge of 'the bush' to younger generations, most of whom now live in urban centres . . . [this] can ensure younger whānau have an embodied and emplaced experience of their belonging in this place as their tūrangawaewae (place of belonging)." [74] Iwi (tribal) control, self-determination and autonomy Iwi control, self-determination and autonomy were described as important to the wellbeing of Māori [67,72,73], not only to the individual, but also to the collective [73].
Individuals and the collective need to be able to exercise self-determination, which results in agency and autonomy over Māori people's lives, including individuals and the whole iwi [67,72,73].
"The ability for Māori leaders to not only be self-governing in their behaviour, but to develop others' autonomy and self-determination, triggered satisfaction and consequently enhanced well-being." [73] Two papers highlighted the importance of iwi sovereignty over decision making of service provision and policy for Māori communities [67,73]. This was exemplified in the context of housing and homelessness, where the value of addressing issues at a community level was highlighted as imperative to promoting wellbeing of all Māori [67,73].
" . . . a duty of iwi to act on their position as "sovereign iwi nations" was identified by several of the respondents . . . public policy discourse around iwi taking charge of the responses to the needs of their populations." [67] Manaakitanga-to extend aroha (love/compassion) and mana (respect/power) to others Seven papers spoke about the importance of manaakitanga to Māori wellbeing [62,64,67,71,72,74,75]. Relationships and social networks were seen as invaluable to Māori wellbeing as they facilitated sharing of important resources, such as food, income, and health care [64]. A fundamental Māori value that underpins the provision of this support is manaakitanga, which represents the extension of aroha (love/compassion) and mana (respect/power) to others [62,67,71,75]. This custom has practical applications and implications for Māori, by encouraging the sharing of resources critical to wellbeing. For example, in many settings, the food security of individuals, whānau (family) and the whole iwi (tribe) is underpinned by manaakitanga [62].
Manaakitanga is also important to bringing and maintaining wellbeing and inner balance through the act of serving and providing for others [71,75]. This reciprocal relationship, whereby the giver and receiver both benefit, is a deeply spiritual aspect of manaakitanga whereby the "purpose of life is to serve others [75]".
"Reciprocity is at the heart of manaakitanga, and rests upon a precept that being of service enhances the mana (authority/power) of others . . . Manaakitanga transforms mana through acts of generosity that enhances all, produces well-being . . . uplifting the mana of others in turn nourishes one's own mana." [75] Colonisation and Māori-Pākehā (European) relations Colonisation and Māori-Pākehā relations were reported by seven papers as having a negative effect on Māori wellbeing [63,67,[69][70][71][72]75]. While colonisation may have affected other aspects of Māori wellbeing, the included papers focused on the impact of colonisation on tikanga (Māori customs), principally through the loss of autonomy and iwi (tribe) control.
" . . . participants described barriers to participation in planning and active exclusion of Māori from decision making; for example, actions of the local council were identified as symptomatic of ongoing colonisation and oppression. A lack of voice in decision making . . . " [70] This disempowerment was acutely felt by Māori who saw this Pākehā control as having a direct influence on Māoritanga (identity), wellbeing and physical health. Conflicts between Māori and Pākehā were evident through interpersonal racism and institutional racism within the systems of health and politics that create significant barriers for Māori [71,72].
"Participants conveyed feelings of grief and shame at being culturally disenfranchised . . . As long as Pākehā [colonisers] or politics are always running these [health care systems], I don't know if we're going to get any better." [63] Kotahitanga-Togetherness and Connection The importance of kotahitanga to Māori wellbeing was reported by 13 papers [62][63][64][65][66][69][70][71][72][73][74][75][76]. Kotahitanga encompasses the Māori concept of togetherness and connection [78]. The included papers referred extensively to different aspects of kotahitanga as they relate to wellbeing, most commonly via Māori relationships to the physical environment through kaitiakitanga (guardianship of land), with whānau, hapu and iwi (whakapapa-genealogies), and relationships in general (whanaungatanga). While, within Māori ideology, whakapapa (genealogies) is encompassed by kotahitanga, due to the significant importance of this Māori aspect to wellbeing, and its extensive coverage across the papers, it is described as a separate theme.
Fulfilling kaitiakitanga is culturally embedded [63,75]. Māori connection to the physical environment is spiritually based and Māori consider themselves as being "of " the environment [63,69,74,75], which, in turn, contributes to Māoritanga (identity) [66]. This sense of spiritual connection was described as unifying the individual in the environment, which was a central quality underpinning wellbeing. In one paper, Māori healers outlined how transgressions against the land directly affect the health of the individual [69]. The intricate symbiotic relationship between Māori and the land is described as a direct relationship between the wellbeing of both [76]. This two-way relationship gave Māori the freedom to live off the land and stay away from larger cities, which improved overall wellbeing [64].
" . . . also understanding the relationship between the health and wellbeing of ourselves as people and the health and wellbeing of our lands, of our rivers, of our oceans, of our mountains, of all of the environment. So, I think there are definite links between the health and wellbeing of people and the health and wellbeing of our environment." [76] Kaitiakitanga was also described as important to Māori relationships with people, fostering stronger ties between people and building Māoritanga (identity) [64]. When Māori are displaced from the land, they reported feeling grief, disenfranchisement and cultural displacement [63], and also the undermining of the Māori collective identity [64].
Whanaungatanga-relationships, kinships and sense of family connection The importance of whanaungatanga to Māori wellbeing was reported by six papers [65,[71][72][73][74][75]. Whanaungatanga represents kinships, both formal and informal, that are created through shared experiences [78]. Relationships, especially with significant others, were seen as having an impact on Māori wellbeing via Māoritanga (identity), with one paper citing the need to nurture whakapapa (genealogies) relationships in order to maintain the interconnections of being Māori [74].
The concept of whanaungatanga recognises the importance of building healthy relationships with others outside of whānau (family) [65,75]. The act of supporting the wellbeing of other people is seen as an important part of establishing and maintaining healthy whanaungatanga.
"I always think of whanaungatanga [relationships], manaakitanga [practising respect and kindness] and I think I'm here for the well-being of the people." [75] Whanaungatanga was described as being built and maintained through tauutuutu (reciprocity) and mana (respect), which, in turn, were said to produce positive impacts on the wellbeing of the individual practicing these customs [71,73,75].
Connection to whānau plays an important role in the wellbeing of the individual with healers citing sometimes it is necessary for whānau involvement in order to achieve spiritual and physical healing of Māori [69]. This strong connection between whānau wellbeing and an individual's wellbeing was evident throughout five of the included papers [63,64,69,72,76] and was clearly stated by one paper [72].
The strong interwoven connections within whānau were outlined as an important concept for those in decision making roles relating to Māori. Māori decision making often occurs at an important meeting place that Māori use to facilitate connections, the marae (cultural meeting house) [70,73,74]. The marae and the connections that occur in this place were identified as bringing Māori strength and cohesion [74].
The importance of physical health in the wellbeing of Māori was only spoken of in the context of whānau connection, as it was seen as an enabler of connection rather than important for wellbeing in its own right [62,63].
" . . . not saying that I'm unhappy now but I think if I'd accomplished that [weight-loss] . . . it would mean I'd be able to just do more with my daughter and my partner . . . " [63] Three papers spoke specifically about the importance of kaumatua (elders) and the vital role they play in the wellbeing of the whole whānau, hapu (sub-tribe) and iwi (tribe) as pillars of tradition and living links to whakapapa (genealogies) [70,72,74].
"The presence of elders at hui and other events was highlighted as particularly critical; without their expertise, there was a risk of adverse impacts on the wellbeing of the whole family, including the loss of tikanga (procedures) and kawa (ceremonial etiquette) knowledge." [70] Turangawaewae-sense of place Turangawaewae was described in five papers as important to the wellbeing of Māori [64,65,69,73,74]. Turangawaewae is the concept of having a cultural place to stand [74]; this place is established through long held positionings of whakapapa (genealogies) [64]. This sense of place is seen as a core component to Māoritanga (identity) and keeping the connection of whānau (family) strong and alive [64,65,69,74]. Belonging to a turangawaewae was described as maintaining whakapapa (genealogies) and instilling Māori pride [64,65,74].
" . . . so all those things, spirituality, physical health, mental health, family health, I think are equal in Māoritanga . . . if ones out then the rest is out." [76] Views on wellbeing were purposively sampled from Māori healers in one paper. The authors built a model of what this holistic view on health looks like, using a star to show the interconnections between hinengaro (mind), tinana (body), wairua (spirit), whakapapa (genealogies) and whenua (land) [69]. Rongoa healers explained that the individual is made up of the mind, body and spirit, and when there is disharmony or disconnect, the individual becomes unwell [68]. They emphasised the importance of using this model within the health system to better serve the needs of Māori people [69,77], and Māori people agreed this has a direct effect on wellbeing [77].

Karakia (prayer) waiata (songs), and tohu (signs)
The importance of karakia, waiata, and tohu to the wellbeing of Māori was reported in five papers [63,66,69,72,76]. Participating in karakia and waiata was seen as offering Māori a sense of safety, protection and connecting to Māori culture and traditions, which was said to build resilience [66,72]. Tohu were spoken of as providing important guidance for Māori people [69]. Tohu were related to animals and the natural environment and were important due to strong connections with the environment [69]. Further, these papers described the importance of drawing on these spiritual practices during times of hardship and illness, which helped the whole whānau (family) maintain wellbeing [76].

United States
Of the included studies, 41  papers related to the wellbeing of Indigenous peoples in the United States. The United States comprises of different Indigenous groups (American Indians, Alaska Natives and Native Hawaiians) [2,120], with unique cultures and languages. The biggest group is American Indians and Alaska Natives, who are not only a racial designation, but a legal one [120]. To date, 574 Tribes and Alaska Villages are federally recognised by the United States government as sovereign nations and, therefore, governmental entities [120]. Tribal sovereignty and self-determination, as manifested in Tribal governments, are the basis of Tribal and community culture and life, and underscore all aspects of wellbeing.
Our analysis of the included papers revealed seven interrelated aspects of life as being centrally important to the wellbeing of Indigenous peoples in the United States: Holism (n = 10 papers); Culture (n = 30); Spirituality and Cultural Medicine (n = 28); Tribe/Community and Family (n = 29); Land, Sea and Subsistence-based living (n = 28); Resilience (n = 21); Basic Needs (n = 17).

Holism
The holistic nature of wellbeing was reported by ten papers [87,94,95,99,101,107,108,110,112,117]. Wellbeing among the Indigenous peoples in the United States is a holistic concept placing value on the integration of physical, mental, emotional and spiritual health [87,94,95,101,108,110,112,117], with some explicitly locating the concept of wellbeing within the conceptualisation of the Medicine Wheel that contain the quadrants: mental, physical, emotional and spiritual [87,95,99].
" . . . [wellbeing] is the full integration of the physical, mental, emotional, cultural, and spiritual facets of a person . . . ." [108] In order to realise "full integration", ten papers reported the importance of finding balance [87,94,101,107,110,117], which could be maintained or achieved through strong spiritual and relational connections [95,101,107,112,117], and maintaining a sense of cultural identity [107].
"The Elders . . . teaching [the youth] traditional values and lifestyles and incorporating Western technology with subsistence activities, all of which contribute to their emotional well-being." [106] Language The importance of one's Indigenous language to the wellbeing of Indigenous peoples in the United States was reported by eleven papers [79,80,85,86,92,94,97,98,101,107,116]. Acculturation that followed colonisation saw the progressive loss of Indigenous languages in the United States over time, resulting in grief and concern [80,85,86,92,97,98,101,107,116].
"When asked why language is so important Alayna replied, 'it's really important to our overall health and well-being. It has everything to do with who we are and we're getting further and further away from that.' . . . " [101] "I feel sad because I don't speak Navajo, I know that I lost something." [86] Physical Activity Physical activity was reported as important to the wellbeing of Indigenous peoples in the United States in the context of culture (including Tribe/community) by seven papers [79,80,94,96,106,118,119]. Conversely, the desire to be more physically active was proposed through cultural activities to increase cultural engagement.
"[United States Indigenous Peoples'] emphasized the belief that the path to true wellness and health implies matters of not only physical well-being, but functions of spiritual and mental health as well. Inherent in this idea of holistic balance is that traditional medicine is one of the primary pathways to restoring the imbalance . . . ." [110] Higher Power or Energy The belief and connection to a higher power, or energy, were reported by 14 papers as important to the wellbeing of Indigenous peoples in the United States [80,[85][86][87][91][92][93][94][95]99,106,107,111,113]. These powerful and spiritual entities were described as providing rules to live by in order to maintain wellbeing [80,85,87]. In return for abiding by these rules, these spiritual entities provided healing and resources (food, water and medicines) [80,85,87,93,94,107,111,113], and both mental and spiritual balance (e.g., the Medicine Wheel described earlier) [80,91,92,95,99,106,107]. The connection to a higher power was strengthened and maintained through respect [80,85,86,113], cultural ceremonies [80,91,92,94,107,111] and Indigenous languages [94].
"The Holy People are understood to play a crucial role in the efficacy of the ceremony and in maintaining one's health and well-being throughout life." [107] "Ceremony and language remind people of 'how all is a part of me and we are all a part of this,' including nature and connection to higher powers, and how the continual work to 'restore balance' ensures the wellness of all parts." [94] Cultural Medicine Cultural medicines, including ceremonies and dances, were reported as important to the wellbeing of Indigenous peoples in the United States by 19 papers [80][81][82][85][86][87]89,91,[93][94][95]97,99,101,107,108,110,111,119].
"After our community performed this ritual we felt a difference among each other and in our homes and lives. We all felt lighter and happier. We smiled at each other more easily and things got better for our young people. The ritual brought us together and together we were stronger." [80] Cultural dances were reported as balancing the four aspects of wellbeing [108], giving Indigenous peoples in the United States renewed strength and pride [101]. They were used as a means to connect with ancestors and a higher power, by both asking and thanking them for resources [80,86].
Family connection was seen as essential to passing down cultural knowledge and how to live in the colonised world [80,84,86,88,89,96,97,101,105,112,114,118]. This sense of family connection went beyond the physical, to strong spiritual connections to ancestors and future generations, and this acted as a guide in the present [89,101,112,113].
Connection Indigenous peoples in the United States' connection to land and sea was reported by 13 papers as important to wellbeing [80,85,91,93,94,96,101,107,[112][113][114]117,118]. This deep connection was felt through a sense of identity and a sense of belonging, with the land and sea providing connection to ancestors and each other [80,91,93,94,96,101,107,113,114,117,118].
"When we think about a healthy community . . . it includes . . . love of our natural world . . . and recogn(izing) our deep connection to it." [94] " . . . I am . . . a spiritual being connected to land, mountain, sea, especially the ocean . . . ." [113] Sacred Provider The land and sea/water are sacred to Indigenous peoples in the United States [91]; it provides for them through subsistence-based living [80,84,85,[104][105][106]116,119] and through their spiritual connections to land [91,107,112,113], as well as providing healing and protection [80,85,91,107,112,113,119]. When displaced from their varying homelands, they become unwell, both physically and mentally [91,93,101,113,114,117]. In order to maintain connection, the land and sea must be cared for and respected [80,85,99,112,113,119].
"Health comes from the land, and how we take care of the people and the land." [85] Subsistence-based living can be defined as " . . . the traditional economy, living on the land and with the land, that brings meaning to Aboriginal peoples" (Simon Brascoupé) [121]. Subsistence-based living, including "living off the land" [84] and cultural foods, was reported as important to the wellbeing of Indigenous peoples in the United States by 18 papers [79][80][81][84][85][86][87]94,97,100,102,[104][105][106]112,116,118,119]. Farming, hunting and gathering of foods brought families and Tribes/community together, giving them a sense of belonging and connection [80,84,104]. It also relieved the financial strain on households, by providing foods and cultural medicines [84,105,116]. It was reported that the movement away from subsistence-based living resulted in suffering and ill-health in the Tribe/community [80,81,85,86,94,100,106,112,116,119].
"Many participants expressed that this subsistence lifestyle is at the core of wellness for Yup'ik people, frequently referring to it as 'the lifestyle' or 'the way of life'." [119] Cultural foods were reported as important to the wellbeing of Indigenous peoples in the United States [79][80][81]86,87,94,97,100,102,105,106,112,118,119]. Cultural foods were seen as nutritionally superior to modern Western foods, sustaining health in the past and today [79,81,86,94,100,106,119]. Some foods were considered especially important due to their medicinal and spiritual properties [81,94,102,119]. Cultural foods were seen to provide connection socially to each other, and culturally to home, especially when individuals were displaced [94,102,112,118].
"Consistent with this emphasis on the subsistence lifestyle for health and wellness, participants in all focus groups remarked on the superiority of traditional natural foods over store-bought food that is processed and imported. Participants described how native foods provide better nutrition, better taste, keep hunger satiated for a longer time and increase physical health." [119] Resilience Resilience, and the consequent adaptation and need for autonomy, was reported by 21 papers as important to the wellbeing of Indigenous peoples in the United States, especially in the context of living between two worlds (pre-colonisation and post-colonisation) [79,80,82,86,[89][90][91][95][96][97][98][99]101,103,104,106,107,110,113,116,117].
"When probed on what it was that brought tears to her eyes, she added, 'I think it's just knowing what we went through and that we're still trying to keep our culture and still live in the modern way that we have to'." [86] There were mixed views on the combining of both cultural spiritual beliefs with Christian ones, with some believing this improved wellbeing and others expressing a need to go back to solely cultural spiritual values [82,86,91,95]. Indigenous peoples in the United States found strength through cultural values and practices, while navigating the Western world [101,107]. Colonisation and resultant acculturation brought conflict in families trying to co-exist, guilt and loss of identity in not knowing culture, and was attributed to negative behaviours in the Tribe/community, ultimately impacting on wellbeing [97,101,116,117].
Having autonomy, adapting to the Western world, and building resilience was reported by 13 papers as important to the wellbeing of Indigenous peoples in the United States [79,86,89,90,96,98,99,101,103,104,113,116,117]. Autonomy was achieved through building resilience and adapting to the "two worlds", which worked to ensure the continuation of cultures in the face of racism and prejudice from the dominating Western culture [86,89,96,101,103,113,116,117]. This brought the ability to achieve goals, which resulted in a more positive outlook [104,106,117].
" . . . participants and workgroup members also emphasized the capacity for resiliency, adaptation, and cultural renewal evidenced by [the Indigenous peoples in the United States]." [117] "Gaining independence enhanced the well-being of many participants . . . Learning to adjust was essential for participants who maintained well-being." [103] Basic Needs Basic needs were reported as important to the wellbeing of Indigenous peoples in the United States by 17 papers [81,86,87,90,91,[94][95][96]100,101,103,105,110,111,115,117,118].
Money and employment were reported together, with other aspects of having employment not reported as being as important as earning [86,87,90,96,100,105,115,117,118]. The desire for money was to meet the needs of the family [86,87,100,103,115], such as food security and for housing [81,86,87,90,100,103,105,117]. A lack of money was seen as impacting wellbeing through the inability to purchase healthy foods and depleted mental health resulting in substance abuse [86,96,100,105,115].
"Not having to fret about simple things like food. To be able to not lavishly but comfortably do things you'd like to do. Basically that everyone is healthy. I don't really look at it so much as status but I mean, just being financially sort of stable . . . Well-being is a roof over our heads, clothes on our backs, food in our stomachs, and our health." [87] "Her jobs were demanding, stressful, and took away from family time, all of which may have contributed to diminished well-being." [103] Services, both health and social, were considered important to wellbeing, specifically physical and mental health [81,86,87,90,91,[94][95][96]100,101,110,111,117,118]. Services needed to be attuned to the individuals needs and treat them with respect, with some preferring Indigenous service providers [81,[94][95][96]101,110,111,117]. Access to services was also reported as important, via location, affordability, transportation and timing [81,86,87,91,100,117,118].
"For most of the participants, it was best if the care provider was Hawaiian or knew Hawaiian ways and respected Hawaiian culture." [81]

Discussion
Our analysis of the literature identified seven themes of wellbeing of Indigenous peoples in Canada, five themes in Aotearoa (New Zealand) and seven themes in the United States (see Table 2). While we found that concepts of health and wellbeing were commonly conceived by Indigenous peoples as holistic and collectivist, wellbeing was not experienced uniformly across all Indigenous populations. These differences reflect the diverse social, political, cultural, environmental and economic contexts of Indigenous peoples' lives [3]. Notwithstanding the marked variations in wellbeing across the populations, some shared elements emerged. Similarities, for example, in identity, connection, balance and self-determination, were found across countries.  In this review, identity was strongly linked to Indigenous peoples' connections with family, Tribe/community, culture, the land, genealogy, and spirituality. It has been argued that these interconnected aspects of identify are integral to Indigenous peoples' wellbeing and disruption to any of these aspects can be detrimental to Indigenous people both individually and collectively [122]. In this review, identity was commonly seen as being built and strengthened through practicing cultural ways, speaking or learning one's Indigenous languages, and through reciprocal connections with the land and sea. Such practices have been referred to as "acts of renewal" [122] and, along with cultural knowledge (and Elders, as key knowledge holders), were commonly viewed by participants in included studies as major facilitators of a strong and proud identity and critical for the wellbeing of families and Tribes/communities. In all three countries, the reciprocal relationship between Indigenous peoples and the land, both in terms of the environment broadly and specifically, and their ancestral homelands, was emphasised. Indigenous people saw themselves as caretakers of the land and, in turn, saw the land as a source of physical and spiritual wellbeing, a finding also reported in the Australian review [11].
Similar to the findings of the Australian review [11], we found that balance of one's mental, physical, emotional and spiritual aspects of life was seen as fundamental to Indigenous peoples' wellbeing. Indeed, while we have separated these and other elements of wellbeing into somewhat artificial themes, it must be noted that they are interconnected and need to be considered in conjunction with each other to understand wellbeing for Indigenous peoples. In some of the included papers from Canada and the United States, Indigenous peoples' wellbeing was conceptualised within the Medicine Wheel and its teachings. The Māori peoples of Aotearoa (New Zealand) had a similar underlying philosophy of wellbeing that also includes whakapapa (genealogy). Whakapapa encompasses connections between people, places, and times, thus linking family, land, and ancestors. Indigenous people in Canada and the United States spoke about the importance of these and described family, land and ancestors as underlying other themes of wellbeing, despite not arising as a distinct theme in itself.
Self-determination is a central element of wellbeing for Indigenous peoples [11,122], a finding that also emerged in the current review. While self-determination theory posits that it is important for the wellbeing of all people [123,124], for Indigenous people, selfdetermination extends beyond the psychological to all other aspects of life, including political, social, cultural, and economical [125]. In the current review, we found that exercising self-determination resulted in increased autonomy and agency of both the individual and the collective. An important aspect of self-determination was the ability for Tribes/communities to self-govern, based on the best interests of the Tribe/community. Self-determination was also evident through resilience in the face of ongoing colonisation, and the associated intergenerational trauma, stigmatisation and racism. Such resilience was seen to contribute to the continuation of culture, a finding echoed by Corntassel (2012), who argued that through decolonisation and resurgence "our homelands will recognise us as being Indigenous to that place" and future generations will have the freedom to "live more Indigenous lives" [122].
While there were commonalities in the themes across the three countries, it is important to note where the experiences of wellbeing diverge. For example, when looking at basic needs for individuals and Tribe/community, the Indigenous peoples in Canada and the United States reported very similar needs including adequate housing, food security and the need for culturally safe services. In Aotearoa (New Zealand), Māori people did not directly report these things as being important to their wellbeing-rather, only mentioning basic needs within the context of relationships and social networks, and how these important connections facilitated these needs. This finding echo's those of Cram and colleagues (2003) who reported Māori conceptions of health were "traditional", being holistic in nature, with the health of the whanau (family), hapu (sub-tribe) and iwi (tribe) stated as important [126]. This focus on the higher levels of Maslow's Hierarchy of needs by Māori may be indicative of a widespread connection to culture, as when one is displaced from their culture, it has been found it is difficult to see past the first level of survival [127]. This is reflected in our findings also where the Indigenous people in Canada and the United States had quite varied experiences with the loss of culture, from those who felt deeply connected, to those who expressed feelings of complete disconnect.
There was an undercurrent of experiences with racism, particularly systemic and institutional racism, along with discriminatory practices that impede wellbeing in some of the included articles. This was particularly evident in terms of resilience and resistance (Canada and the United States) and also in terms of impact (e.g., on identity and power balances in Aotearoa (New Zealand)). Investigating this phenomenon and its impact on wellbeing warrants examination as a primary aim of future research.
Our review highlights the importance of understanding what constitutes wellbeing for Indigenous people. This is particularly so when developing policies and programs to achieve equity across populations. Our findings suggest wellbeing for Indigenous peoples is not completely congruent with Western biomedical views on health and wellbeing, which underpin most current measures of health and wellbeing. Angell and colleagues (2016) conducted a global systematic review of quality of life measures among Indigenous populations, and reported that only 3 out of 41 studies used Indigenous-specific measures [10]. There is also a need for wellbeing measures that prioritise the perspectives and values of Indigenous peoples [10][11][12]. In doing so, these measures can be used to make informed decisions about the allocation of public health resources to address health and wellbeing inequities for Indigenous peoples globally.
An important limitation of our study is the exclusion of grey literature. This decision was made pragmatically due to the already large scope of this review. However, as community-led projects are not always published in peer reviewed journals, the current review may not have captured these studies, nor the aspects of wellbeing reported in these. Future reviews on the topic of wellbeing in Indigenous peoples should consider inclusion of grey literature from the included countries and this should occur under the guidance of an Indigenous person from the respective country. Additionally, we note that we have included studies in our review that were led by Indigenous and non-Indigenous investigators. We recognise that this may have resulted in a somewhat different understanding of what wellbeing means to Indigenous people compared to if the review had focused exclusively on Indigenous-led studies. However, our review was led by an Indigenous Australian researcher and included guidance from senior Indigenous researchers from Australia (GG), Canada (AK), Aotearoa (New Zealand) (EW) and the United States (MC), particularly around the interpretation of findings related to their respective countries. The methods used to identify the themes described in this paper would have benefitted from having input and guidance from Indigenous peoples from the included countries from the outset. However, due to the COVID-19 pandemic and the timing of the data analysis, this was not feasible. We recommend that future reviews on Indigenous health including wellbeing be led by Indigenous persons from the respective countries, from the design through to interpretation and dissemination of findings.

Conclusions
Our review identified several themes of wellbeing important to Indigenous peoples in Canada, Aotearoa (New Zealand) and the United States. While there were some commonalities between countries, our findings reinforce the understanding that the experiences, priorities, and needs of Indigenous peoples in different places are unique and specific to local contexts. We reiterate previous findings that the conceptualisation of wellbeing for Indigenous peoples goes beyond that typically measured in quality of life measures [11]. Wellbeing measures that can accurately and reliably assess indicators of wellbeing that are important to Indigenous peoples are critically needed to inform health policy, practice and research. Future work to develop such measures needs to be led by Indigenous peoples from the outset.