The association between cultural connectedness and health-related quality of life among Indigenous peoples in the CANZUS countries: a systematic review

Cultural connectedness–the extent to which individuals feel connected to their culture through practices, language, traditions, and identity– is increasingly recognized as a key determinant of health among Indigenous peoples across the life course. High levels of cultural connectedness have been associated with improved health-related quality of life (HRQoL). Although several studies have examined this relationship, the evidence has not yet been comprehensively synthesized. A comprehensive search of six databases was conducted from database inception to June 2024. Searches were updated up to September 2025 to identify observational studies examining associations between cultural connectedness and HRQoL, mental health, or physical health among Indigenous populations in Australia, Canada, Aotearoa New Zealand, and the United States. Two independent reviewers conducted screening, data extraction and risk of bias assessment. Risk of bias was assessed using the Newcastle-Ottawa Scale for cohort studies and its adapted version for cross-sectional studies. Effect direction plots and vote counting were used for synthesis. From 7,444, records, 12 studies met the inclusion criteria (Canada n = 3; Australia n = 1; Aotearoa New Zealand n = 3; United States n = 5). Studies examined HRQoL (n = 2), mental health/well-being (n = 9) and physical health (n = 4), and included infants (n = 1), youth (n = 2), adults (n = 7), and Elders (n = 2). For HRQoL, one study reported a positive association with cultural connectedness and one reported no evidence of association. For mental health-well-being, three studies reported positive associations and six reported no evidence of association. For physical health, three studies reported positive associations and one reported no evidence of association. Across countries with similar histories of colonialism, evidence suggests that cultural connectedness may be associated with better physical health and, for some Indigenous populations, better mental health/well-being. Evidence for mental health/well-being and HRQoL remains less consistent across studies. Further research using culturally grounded measures and rigorous designs is needed to strengthen the evidence base and inform culturally responsive policies and programs that support Indigenous health and well-being across the life course. PROSPERO (CRD42024566110).