1.1 Eliciting community need and preferences within Indigenous communities

Eliciting community needs, opinions, and epidemiological data are important preliminary steps for developing and implementing interventions with Indigenous communities [10-12]. Collaboration with Indigenous communities is key to determine what preliminary data is needed, as well as ensuring the development of culturally driven interventions [1]. To accomplish this, research teams have used a variety of methods, including focus groups [13], community advisory boards [14], concept mapping [15], and surveys [16]. All these forms of data collection can guide intervention planning. Survey methods are specifically useful in understanding the broad community needs and preferences about types of interventions or components needed for intervention development. One example, the Tribal Health and Resilience in Vulnerable Environments (THRIVE) study, used tailored surveys to assess the needs, preferences, and health behaviors among two Indigenous communities [17]. The survey results were used to define participants’ current behaviors and specific needs before designing a social support and physical activity program. This approach helped ensure that the program would be developed to best fit the priorities and preferences of the community, increasing the likelihood of participation [16]. Other Indigenous projects have used surveys to identify health prevalence indicators and participants most urgent needs [16, 18, 19].

1.2 Importance of culture for the health of Indigenous populations

A growing body of evidence illustrates that when culture, including Indigenous history, knowledge, values, and lifeways, is woven into prevention and intervention strategies, there is a significant benefit to Indigenous physical, mental/emotional, and social/cultural health [20-22]. Among Indigenous communities in California, those with better reported overall health had stronger cultural connectedness based on fluency in their Indigenous language, higher participation in cultural practices, and sustained connection to the Indigenous community [23]. A study of Anishinaabe adults found protective effects of traditional cultural activity participation against diabetes risks and outcomes. Cultural engagement was related to lowered blood sugar through the path of reduced apathy [24]. A literature review found cultural interventions and cultural and language knowledge among Indigenous communities protective against cardiometabolic disease risk factors [25].

The buffering effects of a supportive social network developed through cultural connection (tribal, familial, and peer) have been linked to reduced health problems. Youth reporting a strong bond to family, community members, and Elders have shown greater resilience and increased protective factors compared to youth with less cultural identity [20, 26-29]. Emotional support decreases mortality risk by half [30] and social support (including social network type, size, and frequency of contact) is linked to increased survival of a cardiovascular event and reduced recurrence [31]. Social networks reduce stress [32, 33] by creating a system of interconnectedness and feedback loops around positive health behaviors [34] and may be as salient, or more, to improved health outcomes as diet, exercise, and tobacco prevention.

Greater cultural spirituality has also been found to improve the mental health of Indigenous people [35-37]. Across a wide age range (15-64 years old) those who reported greater cultural spirituality were less likely to experience a suicide attempt compared to those reporting less cultural spirituality [36]. Regaining cultural identity and greater connection with cultural practices has also been found to protect against substance misuse [38, 39] and may buffer the negative effects of discrimination, historical loss, and trauma [40, 41]. The accumulation of findings, consistent across time and contexts, establishes the critical role cultural engagement and spirituality play in Indigenous health and wellbeing and as protective factors for Indigenous communities.

1.3 Role of language and cultural/historical knowledge in health and well-being

Indigenous language loss that has occurred through historical oppression has resulted in worsened physical and mental health of Indigenous communities [42, 43]. Indigenous communities recognize “that language is the medicine” [44; p. 862] and is needed to bring back health and balance to their communities. Using and revitalizing Indigenous language and knowledge increases cultural connectedness and is associated with positive health and well-being making it a particularly salient protective factor for health risks [45-47]. Around the world, maintaining or revitalizing Indigenous languages is associated with positive mental and physical health [43], and improved social and educational outcomes. In Indigenous communities in Canada where at least over half of the community fluently spoke their native language, a near zero suicide rate was found in the youth population (only 1 youth from 1987 –1992), compared to the communities that had fewer native speakers or less knowledge of their native language (84 youth from 1987 – 1992) [48]. Additionally, compared to six other cultural indicators (e.g. self-governance, access to traditional land, facilities for preserving culture, etc.), language knowledge and use had a greatest effect on the reduction of suicide rates among youth [48]. Another study found that strong language use and cultural practices were linked to a reduction in obesity, diabetes prevalence, and cardiovascular disease [49]. Common quantitative measures of socioeconomic status and education could not account for these differences [49]. Consistently, the literature demonstrates that language plays an essential role in Indigenous health and well-being. This is echoed in two reviews regarding the health of effects of Indigenous language use demonstrating that language use is associated with positive mental and physical health outcomes [42, 43]. Therefore, it is vital to gauge the level of use, proficiency, and community needs in preserving and expanding native language. The right to, access to, and use of Indigenous language is an issue of sovereignty, inherent cultural rights and lifeways, as well as a public health.

1.4 Culture based interventions in Indigenous communities

The centering of culture preserves Indigenous ways of knowing and living and strengthens cultural connectedness and continuity [50]. Examples of interventions developed by Indigenous people for Indigenous people include a tailored curriculum to teach youth about their heritage, traditions, and culture [51]; the Qungasvik (“tools for life”) intervention [52]; the Traditional Spirituality Program centered on the sweat lodge ceremony [53]; the Remember the Removal (RTR) program [54]; a Lakota ceremonial healing program [55]; and The Healing of the Canoe project [5].

Young adult participants in the Cherokee Nation’s RTR program shared that the experience facilitated their own reflection about historical events and trauma that their ancestors experienced and how their ancestors reacted and endured in the face of oppression, thereby increasing their Cherokee cultural identity, knowledge about Cherokee values, and feelings of resilience [54]. The participants described emotional connections to learning history, gained an understanding of the effects of discrimination, and increased their sense of resilience and belonging, a protective factor for health [54]. After finishing the RTR program, participants had improved physical, mental, and social/cultural health outcomes immediately after completion and at a six-month follow-up assessment [54]. The results indicate that the RTR program had lasting positive health effects for Cherokee young adults across several health domains, reinforcing evidence for culturally driven interventions within a Cherokee population to improve health and well-being.

Similar positive impacts from culturally centered interventions have been found with other Indigenous groups. Among the Lakota, a group therapy program that facilitated a grieving process through traditional Lakota ceremonies helped participants gain more awareness of historical trauma and grief, resulted in feelings of relief [55], and a newfound commitment to facing historical trauma, while helping their community heal through traditional practices [55]. A traditional hula dance program for Native Hawaiians significantly improved blood pressure and reduced cardiovascular disease risk [56]. Finally, for Suquamish and Port Gamble S’Klallam youth, participating in a four month culturally driven curriculum centered on the canoe journey increased their sense of hope, optimism, and self-efficacy and reduced substance use [5]. Research using tribally-based cultural interventions results in positive health outcomes and promotes the health and well-being of Indigenous people and communities.

2.1 Indigenous research/decolonizing methodologies

Interventions with Indigenous communities often utilize approaches developed for non-Indigenous populations and then seek to adapt them with limited or no consultation with the target population. In contrast, the methodology used for this research draws on the RTR program, a 30-year-old community-derived initiative created by citizens of the Cherokee Nation. Building off the deep-seated RTR program minimizes potential cultural and ethical violations (e.g., helicopter research, culturally incongruent interventions, etc.) that are common in most research projects with Indigenous communities. This approach also empowers the Cherokee Nation and its citizens to address their own needs using their own values and skillsets.

A critical component of this research is the use of community/tribal-based participatory research (C/TBPR) principles [57] and Indigenous methodologies [58] to partner with the Cherokee Nation. In CBPR, a multidisciplinary team utilizes a flattened hierarchy to approach issues that have been prioritized by community members [59]. Indigenous research methods use Indigenous beliefs and knowledge throughout the research process to guide researchers and restore equity and balance to Indigenous communities [58]. The research question, methods for change, and the interventions must also be community-derived [60] and tailored to the region, community, and culture [61]. Specific CBPR and Indigenous research orientations and methodologies utilized by the research team involved privileging Cherokee-specific ways of being, including meeting styles, cultural protocol, and decision-making processes. The partnerships developed and strengthened through this process can lead to changes in policy and procedures, community action, and improved health outcomes that are defined by both community members and the research team [62-64].

A community advisory board (CAB) (n=9), as well as a history and culture committee (n =4) were formed to create a program to improve cultural connectedness and Cherokee cultural and historical knowledge. Board and committee formation was built upon a previous research project collaboration (e.g., Remember the Removal) in which members envisioned a new project that would focus on Cherokee community revitalization [13]. The history and culture committee was made up of four expert Cherokee historians: three Cherokee Nation citizens, two affiliated with the RTR program, and two PhD level academics. The community advisory board was comprised of nine Cherokee Nation citizens; six were affiliated with the RTR program, two were Cherokee elders, and areas of expertise of the CAB included Cherokee history, mapping, language, mental health, physical health, traditional games, and community programming. To effectively create the program, the board and committee decided to solicit information from Cherokee citizens about their historical and cultural knowledge, their interest in learning more about these topics, and the preferences regarding program implementation. Survey questions were developed collaboratively by the PI, the history and culture committee, the community advisory board, and the PI’s mentors. Cherokee linguists, Cherokee historians, sociologists, cardiovascular physicians and Cherokee community members were among those who contributed to the instrument creation.

2.2 Authors´ positionality

The study population in this project were Cherokee citizens. The lead author and principal investigator of the study, Dr. Melissa E. Lewis, is a citizen of the Cherokee Nation. Cherokee Nation citizens were engaged in the study from idea formation, throughout the project including dissemination. Specifically, the study was co-designed by a history and culture committee and community advisory board in which 12 of 13 are Cherokee Nation citizens. The committee and board met monthly for one year to create the research design and study instruments. All study participants reported that they were citizens of a Cherokee federally recognized tribe. Post-survey, the committee and board met again several times to interpret and write the results of the study. All committee and advisory board members were invited to participate in this manuscript as authors. Study results in this manuscript were also presented to a group of Cherokee citizens involved in the larger intervention project for review and editing before dissemination. Of the manuscript authors, 8 of 11 are Indigenous, 3 of 4 of the history and culture committee are represented and 2 of the 9 community advisory board members are authors.

2.3 Study context

With over 400,000 registered tribal citizens, Cherokee Nation (CN) is one of the largest federally recognized tribes in the US [9]. The Cherokee Nation comprises 14 counties in Northeastern Oklahoma and is home to 63% of Cherokee citizens and 200,000 other Indigenous peoples. Indigenous people living in the CN have a lower median income ($44,554) [9] and high school completion rate (82.9%) compared to the state average (86.7%) [65]. Federal policies over many eras banned Cherokee cultural and traditional practices including family customs, traditional community living, and traditional Cherokee spirituality (until the Indian Religious Freedom Act in 1978). The Cherokee language was banned in public schools and places due to allotment era policies [66]. Cherokee youth today lack access to Cherokee history education at school and at home and have less access to traditional cultural activities than prior generations. The reduction of Cherokee language use and cultural knowledge and practices have become a critical and growing issue. As a result, there are less than 1500 fluent speakers of the Cherokee language with the average age of around 65 years or older [67, 68].

2.4 Study population and data collection

The study population included Cherokee citizens over the age of 18. Data was collected using a self-administered anonymous online Research Electronic Data Capture (REDCapTM) survey. Participants were asked to read and sign an informed consent before completing the survey. The survey link was shared on the Cherokee Nation’s Facebook page, which receives extensive traffic. The survey was available for an 8-month period and took an estimated 15-20 minutes to complete. Upon completion, respondents were entered into the chance to win one of three $50 gift cards.

2.5 Measures

Survey questions included demographic information (i.e., age, gender, income, education, tribe affiliation, and whether the participant lived on or off the reservation) as well as questions related to knowledge and interest in Cherokee history, traditional cultural activities, language, and cultural connection, as well as self-reported physical and mental health information. For this manuscript’s purposes, we will focus on knowledge, interest, and culture. This is the first time these instruments have been used. Questions were created, edited, and piloted by the committee and CAB until a consensus was reached regarding all assessments.

2.6 Cultural knowledge, connection and language use

Knowledge of history. Respondents were asked how knowledgeable they were about five key periods in Cherokee history identified by the CAB. Periods included pre and early contact (pre-1690), pre-revolutionary (1700´s-1791), long removal (1760s-1830s), US Civil War (1830s-1860s), and the allotment era (late 1800s-1930s). Each question included a description of events that marked each period (historical period definitions can be found in Supplementary material 1). Response options ranged from No knowledge (0) to Very knowledgeable (4). Respondents were also asked yes/no questions regarding if they knew when family was removed from traditional homelands, family membership in Union or Confederate regiments, location of family allotment land, and continued family ownership of allotment land. A total score was created by taking a sum of all 5 items (range from 0-20), internal reliability for the knowledge items was excellent (Cronbach’s alpha = .91).

Tribal community connection. Respondents were asked “How connected do you feel to your tribal community?” Response options ranged from Not at all connected (0) to Very connected (4).

Traditional beliefs. Knowledge of traditional beliefs was assessed by asking respondents,“How knowledgeable do you feel about traditional Cherokee beliefs, values, and lifeways?” Response options ranged from Not at all knowledgeable (1) to Extremely knowledgeable (5).

Language. Respondents shared their level of proficiency in understanding, using, and speaking the Cherokee language (see Table 2 for proficiency levels). These items had high internal reliability (Cronbach alpha = .94). There were also yes/no questions asking respondents if their grandparent was fluent in Cherokee, if their parent was fluent in Cherokee, and if they heard Cherokee spoken in the home while growing up.

2.7 Interest in cultural learning

Learning history. Interest in learning history was assessed by asking respondents their interest in learning more about each of the five key periods referenced in the Knowledge of history measure (pre and early contact, pre-revolutionary, long removal, US Civil War, and the allotment era). Response options ranged from Not at all interested (0) to Very interested (4). A total score was created by taking a sum of all 5 items (range from 0-20). Internal reliability for the historical items was excellent (Cronbach’s alpha = .91).

Learning traditional activities and values. Respondents were asked their level of interest in learning (Not at all interested - Very interested) traditional activities like stickball (i.e., a precursor to modern day Lacrosse), basket making, pottery, and cooking, traditional cultural values (e.g., Gadugi-this word means people coming together as one and working to help one another), and spirituality like prayers, daily practices, and stomp dance. Internal reliability for the interest in activity items was acceptable (Cronbach’s alpha = .65).

Learning language. Respondents shared their level of interest in learning (0 = Not at all interested – 4 = Very interested) key words, basic conversation, and reading and writing in Cherokee. Internal reliability for the language items was excellent (Cronbach’s alpha = .86).

2.8 Scheduling preferences and time allotment

Scheduling. Scheduling preferences were assessed by asking respondents the likelihood (Not at all likely (0) - Very likely (4)) that they would take 1-2 and 3-5 days off from work/school a month to learn about Cherokee history, culture, and language within the Cherokee Nation 14 county jurisdictional area. Respondents were also asked the days/time (e.g. Friday night) that would be most feasible for them to participate and the learning timeline (Meeting once a month for up to one year (0), Meeting twice a month for 6 months (1), or Meeting 2-3 times a month for 3 months (2)) that would be most preferable.

Dedicating time. Respondents were asked the likelihood that they would dedicate 1-2 hours and 3-5 hours to reading/homework a week. Response options ranged from Not at all likely (0) to Very likely (4).

2.9 Analysis

Descriptive statistics were examined for all survey responses. To assess sample demographic differences among respondent knowledge/interest of Cherokee culture, history and language, chi-square (X2) analysis, t-tests for continuous variables, and Analysis of Variance (ANOVA) was utilized. Differences among sample demographics included gender, age, and whether the respondent lived on or off the reservation at the time of the survey. All analyses were performed using SAS, version 9.4.

2.10 Ethical considerations

All study materials and protocols were approved through the University of Missouri IRB and the Cherokee Nation IRB. This manuscript was approved by the Cherokee Nation IRB before dissemination.

3.1 Characteristics of participants

A total of 355 participants completed the survey. All participants reported that they were citizens of a Cherokee federally recognized tribe. Most participants identified as being Cherokee Nation citizens (98%) and female (74%), with a mean age of 45 years (SD = 12.65, range = 25-86 years; see Table 1). Thirty-seven percent of participants reported their annual household income as being greater than $60,000, with 56% having received a college degree or higher. Nearly half (44%) of participants reportedly live on the Cherokee Nation reservation.

3.2 Knowledge of history, culture, and language

When participants were asked about their knowledge of Cherokee history, 60% (or greater) reported little (1 = ‘little knowledge’) to no knowledge (0 = ‘no knowledge’) about the pre- and early contact period, the pre-revolutionary period, the civil war period, and the allotment era. Forty-eight percent of participants, however, reported having ‘some knowledge to being very knowledgeable’ about the long removal period. Half (50%) of participants remembered when their own family was removed from their traditional homelands. Similarly, 39% of participants (n = 140) reported knowing where their family allotment land is and 43% of these (n = 60) reported that it was still owned by a family member.

Mean scores for tribal connection and traditional knowledge were 2 (neutral) and 2.4 (slightly knowledgeable). When asked about their proficiency in understanding and speaking the Cherokee language, more than 70% can understand and/or speak 20 words or less of the Cherokee language, with the majority (58%) only able to speak 0-9 words. Only 22% reported to have heard Cherokee spoken in their home growing up while 11% reported that their parents were fluent in the Cherokee language (see Table 2).

When taking gender into account, male respondents reported higher levels of knowledge about Cherokee history than female respondents (7.49 vs. 5.57 respectively, t = 3.54, p =.0006), (Table 3). Additionally, males reported higher knowledge about Cherokee culture (connection to community and traditional beliefs), than female respondents (p <.05). Also, a higher percentage of male respondents reported that the Cherokee language was spoken in their home when growing up as compared to female respondents (33 vs 19% respectively, X2 = 6.41, p = .01). There were, however, no gender differences noted regarding the respondent’s understanding and/or speaking of the Cherokee language.

Older respondents (> 50 years) in general reported higher knowledge of Cherokee culture, specifically their connection to the tribal community (F = 3.59, p = .02). Respondents living on the reservation also reported higher levels of Cherokee cultural knowledge including tribal community connection (t = 4.75, p <.0001) and traditional beliefs (t = 3.65, p = .0003) as compared to those living off the reservation. Furthermore, respondents living on the reservation reported higher language proficiency for both understanding and use/speaking (p < .0001).

3.3 Interest in learning history, culture/traditions, and language

Participants were very interested (70% or greater) in learning more about Cherokee history, including events like pre- and early contact period, pre-revolutionary period, civil war period, and the allotment era (Table 4). Additionally, participants reported high interest in learning more about traditional Cherokee activities (e.g., stickball, basket making), cultural values, and the Cherokee language.

The strong interest in learning more about Cherokee history, cultural practices, and traditions did not vary significantly by demographic group (Table 5). There were some differences in interest in learning Cherokee language. Middle-aged adults (30-49) had significantly more interest in learning the Cherokee language than older respondents (> 50 years), particularly basic conversational terms (F = 4.62, p = .01), as well as reading and writing skills (F = 6.47, p = .001). Additionally, off reservation respondents reported more interest in learning the Cherokee language, particularly key words (t = 1.98, p = .04).

3.4 Likelihood of program participation

In terms of scheduling time for cultural learning, participants reported that they were more likely to take 1-2 days off from work a month (Supplementary material 2). Most participants preferred to attend sessions held over a weekend (80%) and 47% preferred monthly sessions as opposed to more frequent meeting options. Participants were more likely to dedicate 1-2 hours to homework vs 3-5 hours each week.

4.1 Cherokee language

Most survey respondents (around 60%) can speak only a few Cherokee words (0-9 words) while 17% can say common words and phrases. Less than 1% were fluent Cherokee speakers. This is not surprising given that only around 11% said that their parents were fluent speakers and 39% reported that their grandparents were fluent speakers. This data builds on a 2002 assessment that reported that, at that time, all fluent Cherokee speakers were over the age of 40 and most of their children in their sample were not fluent speakers [75]. Therefore, most fluent speakers today are likely over the age of 60.

Until recent history, the Cherokee language was the primary language of choice and use. While the history of Cherokee language use is not well documented, in 1817, all Cherokees spoke the Cherokee language and about ¾ were bilingual (English) [76]. To ensure the perpetuation of the Cherokee language, those that spoke English during treaty negotiations were fined by the tribe. An 1835 census of Cherokees found that twice the number of Cherokees could read Cherokee compared to English (2,714; 1,071) demonstrating a Cherokee preference for reading and writing [77]. A photo of Cherokee Nation Principal Chief John Ross in 1866 has comments written in Cherokee demonstrating his language fluency [78]. In 1872, a report from the Annual Report of the Board in Indian Commissioners shared that, “While at most the whole of Cherokees who do not speak English can read and write the Cherokee by using the characters invented by Sequoyah [79] (p. 159),” suggesting that Cherokee literacy was near 100% at that time.

An anthropological report of four Cherokee communities in Oklahoma in 1964, found that, “At present, Cherokee is the language of Cherokee settlements. At community gatherings virtually all formal discourse and most informal conversation is in Cherokee [80].” The author noted that for most Cherokees, the Cherokee language was their first language and was learned in the home. The report found no community in which English language was the primary language and shared that English is only learned in school [80]. Even for Cherokee communities that used English, the Cherokee language was still found to be the primary language for more than half of those households. The report concludes that the “older (Cherokee) generation wants to hang on to its language [80],” and that is why the use of the language is so pervasive. Further, the author writes a moving statement about the role of Cherokee language within Cherokee culture; “It is becoming apparent that Cherokee is spoken at such times not only because Cherokee speakers exist, but also because use of Cherokee defines the event as a Cherokee event,” [80] highlighting the centrality of the Cherokee language to Cherokee culture.

The 1964 anthropological report occurred during the final stages of the boarding school era (1869-1960s) [81] and the effects of this era have proved devastating for the Cherokee language. During the 1920’s, over 80% of Indigenous children in the United States were enrolled in boarding schools. During the boarding school era, most fluent Cherokee speakers entered primarily English-speaking environments by the age of 5 years old, thus prohibiting boarding school attendees from passing their language down to their children. At the same time, United States government suppressed not only the Cherokee language, but other cultural lifeways, in large effort to assimilate Cherokees to Western culture [61].

By 2002, only 17% were speaking Cherokee regularly in their home [75]. Fluent speakers reported that this decline started before or during the start of elementary schools and most of their children did not speak Cherokee fluently [75]. In the current study, 22% reported that some amount of Cherokee was spoken at home and less than 1% in our sample were currently fluent speakers (e.g., “I can speak about anything in Cherokee with any Cherokee speaker”). It is important to note that this study did not purposively sample fluent speakers as was the case in the 2002 assessment. Further, technology accessibility and survey interest could also have affected the ability for fluent speakers to participate in this online study, possibly limiting their participation.

Despite US federal government efforts to diminish the Cherokee language, especially in educational settings, Cherokees continued then, and still today, to print their language in public press, radio, and media and to communicate informally in Cherokee through conversation and private writings, which promotes preservation and continuation of the written language [82, 83]. Other Indigenous communities have experienced similar challenges with language loss and share that settler-colonial environments continue to negatively affect language loss and language learning. For example, in a study in Hawaii, participants shared that they struggled to integrate their Indigenous language into their life, which has been dominated by Western culture and driven by expectations of English dialogue [84].

The Cherokee Nation Language Department reports that there are about 2,000 first language speakers of Cherokee across the three federally recognized tribes of Cherokee people (Cherokee Nation, Eastern Band of Cherokee Indians, and the United Keetoowah Band of Cherokee Indians) and several thousand tribal members currently participating in Cherokee language programs [85]. An estimate of 2,000 fluent speakers out of approximately 400,000 federally recognized Cherokees represents a rate of less than 1% of the Cherokee population are fluent speakers, which is consistent with this study’s findings [86]. Also, the 2,000 speakers estimate has not been adjusted to account for the nearly 500 speakers known to have died since 2019 [68, 67]. As mentioned earlier, a 2002 report found that no one younger than 40 had proficient conversational skills and only 17% of speakers use Cherokee in their home [67]. As a result, most children of Cherokee language speakers cannot speak Cherokee [67].

The results of our survey indicate a decline in interactions with and exposure to fluent Cherokee speakers especially for those living off the Cherokee Nation reservation and participants in the youngest age group (20-29), so more outreach to younger generations and/or those living off reservation could have significant positive impacts. Furthermore, most respondents expressed a strong interest in learning more of the Cherokee language. This has been echoed by Cherokees for many years: Through history (1964 [80], 2002 [75]) and even today, as demonstrated in this survey, Cherokees report a desire to be more proficient in speaking the Cherokee language and rate it as very important to impart the language to future generations. A growing body of research has demonstrated that Indigenous language use and revitalization have positive health, social, and educational impacts for Indigenous people [45-47, 43]. Therefore, programs with a strong Cherokee language component may be instrumental in improving Cherokee health and well-being and fulfilling the needs and desires of Cherokee citizens to preserve, revitalize, and actively use the Cherokee language.

Our survey also highlights that most Cherokees feel the need to speak their language and believe its upmost preservation is important for future generations. As the number of parents that speak the Cherokee language is declining, it is drawing their children and families to look for other resources outside of the home to learn Cherokee culture and language. Cultural language loss does not occur in a vacuum and is a critical indicator of the health of a culture.

4.2 Conclusion

This cross-sectional survey provides data and trends regarding Cherokee citizens’ knowledge, interests, and preferences related to cultural connection and learning. Cherokees of all ages, genders, and locations want to know more about their history, traditions, and language and are willing to commit time, over a prolonged period, to further their learning and cultural engagement. Specifically, there is a need and desire for more programs to teach Cherokee history, language, and culture and for citizens to connect to their tribal community. Given the low rates of cultural and linguistic Cherokee knowledge, along with the rapidly decreasing rates of fluent speakers, Cherokees face an impending linguistic crisis, cultural crisis, and, consequently, a public health crisis. However, with the appropriate support and allocation of resources, these crises may be averted. Specifically, research shows that programs focused on traditional cultural beliefs and practices improve physical, mental, and social/cultural health [20-24, 36-40, 42-47, 54]. In addition to health benefits and community desires, language and culture are central to the Cherokee worldview and are critical for the continuity of Cherokee people.

AI utilization

Not applicable.

Competing interests

The authors declare no competing interests.

Funding

Research reported in this manuscript was supported by the National Heart, Lung, and the Blood Institute of the National Institutes of Health under Award Number K01HL142944. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Author contributions

MEL, JDB, RS, JR, SH, and TSW designed the study. MEL, IB, BNA, and JBS wrote the first draft. JBS helped facilitate data collection, conducted data analysis, and created tables. MEL, IB, BNA, JDB, RS, JR, SH, TSW, and HP edited and finalized the manuscript. MEL procured funding for the study. All authors significantly contributed to this manuscript and gave final approval of this manuscript.

Data availability

Not applicable.

Acknowledgements

We would like to thank the research participants for sharing their experiences with us, the advisory board and committee that co-created this project, the Cherokee Nation for assistance with recruiting, and the CNIRB for project oversight. Finally, we would like to thank Alex Henigman for the manuscript formatting assistance.