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Background: Indigenous children living in high income countries have a consistently high prevalence of mental health problems. We aimed to identify psychosocial risk and protective factors for mental health in this setting. Methods: A systematic review of studies published between 1996 and 2016 that quantitatively evaluated the association between psychosocial variables and mental health among Indigenous children living in high income countries was conducted. Psychosocial variables were grouped into commonly occurring domains. Individual studies were judged to provide evidence for an association between a domain and either good mental health, poor mental health, or a negligible or inconsistent association. The overall quality of evidence across all studies for each domain was assessed using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) guidelines. Results: Forty-seven papers were eligible (mainland US 30 [64%], Canada 8 [17%], Australia 7 [15%], Hawaii 4 [9%]), including 58,218 participants aged 4-20 years. Most papers were cross-sectional (39, 83%) and measured negative mental health outcomes (41, 87%). Children's negative cohesion with their families and the presence of adverse events appeared the most reliable predictors of increased negative mental health outcomes. Children's substance use, experiences of discrimination, comorbid internalising symptoms, and negative parental behaviour also provided evidence of associations with negative mental health outcomes. Positive family and peer relationships, high self-esteem and optimism were associated with increased positive mental health outcomes. Conclusions: Quantitative research investigating Indigenous children's mental health is largely cross-sectional and focused upon negative outcomes. Indigenous children living in high income countries share many of the same risk and protective factors associated with mental health. The evidence linking children's familial environment, psychological traits, substance use and experiences of discrimination with mental health outcomes highlights key targets for more concerted efforts to develop initiatives to improve the mental health of Indigenous children. [ABSTRACT FROM AUTHOR]

Background: Appropriate choice of research design is essential to rightly understand the research problem and derive optimal solutions. The Comorbidity Action in the North project sought to better meet the needs of local people affected by drug, alcohol and mental health comorbidity. The aim of the study focused on the needs of Aboriginal peoples and on developing a truly representative research process. A methodology evolved that best suited working with members of a marginalised Aboriginal community. This paper discusses the process of co-design of a Western methodology (participatory action research) in conjunction with the Indigenous methodologies Dadirri and Ganma. This co-design enabled an international PhD student to work respectfully with Aboriginal community members and Elders, health professionals and consumers, and non-Indigenous service providers in a drug and alcohol and mental health comorbidity project in Adelaide, South Australia. Methods: The PhD student, Aboriginal Elder mentor, Aboriginal Working Party, and supervisors (the research team) sought to co-design a methodology and applied it to address the following challenges: the PhD student was an international student with no existing relationship with local Aboriginal community members; many Aboriginal people deeply distrust Western research due to past poor practices and a lack of implementation of findings into practice; Aboriginal people often remain unheard, unacknowledged and unrecognised in research projects; drug and alcohol and mental health comorbidity experiences are often distressing for Aboriginal community members and their families; attempts to access comorbidity care often result in limited or no access; and Aboriginal community members experience acts of racism and discrimination as health professionals and consumers of health and support services. The research team considered deeply how knowledge is shared, interpreted, owned and controlled, by whom and how, within research, co-morbidity care and community settings. The PhD student was supported to co-design a methodology that was equitable, democratic, liberating and life-enhancing, with real potential to develop feasible solutions. Results: The resulting combined Participatory Action Research (PAR)-Dadirri-Ganma methodology sought to create a bridge across Western and Aboriginal knowledges, understanding and experiences. Foundation pillars of this bridge were mentoring of the PhD student by senior Elders, who explained and demonstrated the critical importance of Yarning (consulting) and Indigenous methodologies of Dadirri (deep listening) and Ganma (two-way knowledge sharing), and discussions among all involved about the principles of Western PAR. Conclusions: Concepts within this paper are shared from the perspective of the PhD student with the permission and support of local Elders and Working Group members. The intention is to share what was learned for the benefit of other students, research projects and community members who are beginning a similar journey. [ABSTRACT FROM AUTHOR]

Background: Indigenous peoples often find it difficult to access appropriate mainstream primary health care services. Securing access to primary health care services requires more than just services that are situated within easy reach. Ensuring the accessibility of health care for Indigenous peoples who are often faced with a vast array of additional barriers including experiences of discrimination and racism, can be complex. This framework synthesis aimed to identify issues that hindered Indigenous peoples from accessing primary health care and then explore how, if at all, these were addressed by Indigenous health care services. Methods: To be included in this framework synthesis papers must have presented findings focused on access to (factors relating to Indigenous peoples, their families and their communities) or accessibility of Indigenous primary health care services. Findings were imported into NVivo and a framework analysis undertaken whereby findings were coded to and then thematically analysed using Levesque and colleague's accessibility framework. Results: Issues relating to the cultural and social determinants of health such as unemployment and low levels of education influenced whether Indigenous patients, their families and communities were able to access health care. Indigenous health care services addressed these issues in a number of ways including the provision of transport to and from appointments, a reduction in health care costs for people on low incomes and close consultation with, if not the direct involvement of, community members in identifying and then addressing health care needs. Conclusions: Indigenous health care services appear to be best placed to overcome both the social and cultural determinants of health which hamper Indigenous peoples from accessing health care. Findings of this synthesis also suggest that Levesque and colleague's accessibility framework should be broadened to include factors related to the health care system such as funding. [ABSTRACT FROM AUTHOR]

Background: Given the persistence of Indigenous health inequities across national contexts, many countries have adopted strategies to improve the health of Indigenous peoples. Governmental recognition of the unique health needs of Indigenous populations is necessary for the development of targeted programs and policies to achieve universal health coverage. At the same time, the participation of Indigenous peoples in decision-making and program and policy design helps to ensure that barriers to health services are appropriately addressed and promotes the rights of Indigenous peoples to self-determination. Due to similar patterns of Indigenous health and health determinants across borders, there have been calls for greater global collaboration in this field. However, most international studies on Indigenous health policy link Anglo-settler democracies (Canada, Australia, Aotearoa/New Zealand and the United States), despite these countries representing a small fraction of the world's Indigenous people. Aim: This paper examines national-level policy in Australia, Brazil, Chile and New Zealand in relation to governmental recognition of differential Indigenous health needs and engagement with Indigenous peoples in health. The paper aims to examine how Indigenous health needs and engagement are addressed in national policy frameworks within each of the countries in order to contribute to the understanding of how to develop pro-equity policies within national health care systems. Methods: For each country, a review was undertaken of national policies and legislation to support engagement with, and participation of, Indigenous peoples in the identification of their health needs, development of programs and policies to address these needs and which demonstrate governmental recognition of differential Indigenous health needs. Government websites were searched as well as the following databases: Google, OpenGrey, CAB Direct, PubMed, Web of Science and WorldCat. Findings: Each of the four countries have adopted international agreements regarding the engagement of Indigenous peoples in health. However, there is significant variation in the extent to which the principles laid out in these agreements are reflected in national policy, legislation and practice. Brazil and New Zealand both have established national policies to facilitate engagement. In contrast, national policy to enable engagement is relatively lacking in Australia and Chile. Australia, Brazil and New Zealand each have significant initiatives and policy structures in place to address Indigenous health. However, in Brazil this is not necessarily reflected in practice and although New Zealand has national policies these have been recently reported as insufficient and, in fact, may be contributing to health inequity for Māori. In comparison to the other three countries, Chile has relatively few national initiatives or policies in place to support Indigenous engagement or recognise the distinct health needs of Indigenous communities. Conclusions: The adoption of international policy frameworks forms an important step in ensuring that Indigenous peoples are able to participate in the formation and implementation of health policy and programs. However, without the relevant principles being reflected in national legislature, international agreements hold little weight. At the same time, while a national legislative framework facilitates the engagement of Indigenous peoples, such policy may not necessarily translate into practice. Developing multi-level approaches that improve cohesion between international policy, national policy and practice in Indigenous engagement in health is therefore vital. Given that each of the four countries demonstrate strengths and weaknesses across this causal chain, cross-country policy examination provides guidance on strengthening these links. [ABSTRACT FROM AUTHOR]

Introduction: Healthcare organisations serve clients from diverse Indigenous and other ethnic and racial groups on a daily basis, and require appropriate client-centred systems and services for provision of optimal healthcare. Despite advocacy for systems-level approaches to cultural competence, the primary focus in the literature remains on competency strategies aimed at health promotion initiatives, workforce development and student education. This paper aims to bridge the gap in available evidence about systems approaches to cultural competence by systematically mapping key concepts, types of evidence, and gaps in research. Methods: A literature search was completed as part of a larger systematic search of evaluations and measures of cultural competence interventions in health care in Canada, the United States, Australia and New Zealand. Seventeen peer-reviewed databases, 13 websites and clearinghouses, and 11 literature reviews were searched from 2002 to 2015. Overall, 109 studies were found, with 15 evaluating systems-level interventions or describing measurements. Thematic analysis was used to identify key implementation principles, intervention strategies and outcomes reported. Results: Twelve intervention and three measurement studies met our inclusion criteria. Key principles for implementing systems approaches were: user engagement, organisational readiness, and delivery across multiple sites. Two key types of intervention strategies to embed cultural competence within health systems were: audit and quality improvement approaches and service-level policies or strategies. Outcomes were found for organisational systems, the client/practitioner encounter, health, and at national policy level. Discussion and implications: We could not determine the overall effectiveness of systems-level interventions to reform health systems because interventions were context-specific, there were too few comparative studies and studies did not use the same outcome measures. However, examined together, the intervention and measurement principles, strategies and outcomes provide a preliminary framework for implementation and evaluation of systems-level interventions to improve cultural competence. Identified gaps in the literature included a need for cost and effectiveness studies of systems approaches and explication of the effects of cultural competence on client experience. Further research is needed to explore the extent to which cultural competence improves health outcomes and reduces ethnic and racially-based healthcare disparities. [ABSTRACT FROM AUTHOR]

Background: Indigenous populations throughout the world experience poorer health outcomes than non-indigenous people. The reasons for the health disparities are complex and due in part to historical treatment of Indigenous groups through colonisation. Evidence-based interventions aimed at improving health in this population need to be culturally safe. However, the extent to which cultural adaptation strategies are incorporated into the design and implementation of nutrition interventions designed for Indigenous peoples is unknown. The aim of this scoping review was to explore the cultural adaptation strategies used in the delivery of nutrition interventions for Indigenous populations worldwide. Methods: Five health and medical databases were searched to January 2020. Interventions that included a nutrition component aimed at improving health outcomes among Indigenous populations that described strategies to enhance cultural relevance were included. The level of each cultural adaptation was categorised as evidential, visual, linguistic, constituent involving and/or socio-cultural with further classification related to cultural sensitivity (surface or deep). Results: Of the 1745 unique records screened, 98 articles describing 66 unique interventions met the inclusion criteria, and were included in the synthesis. The majority of articles reported on interventions conducted in the USA, Canada and Australia, were conducted in the previous 10 years (n = 36) and focused on type 2 diabetes prevention (n = 19) or management (n = 7). Of the 66 interventions, the majority included more than one strategy to culturally tailor the intervention, combining surface and deep level adaptation approaches (n = 51), however, less than half involved Indigenous constituents at a deep level (n = 31). Visual adaptation strategies were the most commonly reported (n = 57). Conclusion: This paper is the first to characterise cultural adaptation strategies used in health interventions with a nutrition component for Indigenous peoples. While the majority used multiple cultural adaptation strategies, few focused on involving Indigenous constituents at a deep level. Future research should evaluate the effectiveness of cultural adaptation strategies for specific health outcomes. This could be used to inform co-design planning and implementation, ensuring more culturally appropriate methods are employed. [ABSTRACT FROM AUTHOR]

Introduction: The use of social media and digital technologies has grown rapidly in Australia and around the world, including among Indigenous young people who face social disadvantage. Given the potential to use social media for communication, providing information and as part of creating and responding to social change, this paper explores published literature to understand how Indigenous Australian youth use digital technologies and social media, and its positive and negative impacts. Methods: Online literature searches were conducted in three databases: PubMed, Google Scholar and Informit in August 2014; with further searches of additional relevant databases (Engineering Village; Communication & mass media complete; Computers & applied sciences complete; Web of Science) undertaken in May 2015. In addition, relevant literature was gathered using citation snowballing so that additional peer-reviewed and grey literature was included. Articles were deemed relevant if they discussed social media and/or digital technologies and Indigenous Australians. After reading and reviewing all relevant articles, a thematic analysis was used to identify overall themes and identify specific examples. Results: A total of 22 papers were included in the review. Several major themes were identified about how and why Indigenous young people use social media: identity, power and control, cultural compatibility and community and family connections. Examples of marketing for health and health promotion approaches that utilize social media and digital technologies were identified. Negative uses of social media such as cyber bullying, cyber racism and the exchange of sexually explicit content between minors are common with limited approaches to dealing with this at the community level. Discussion: Strong cultural identity and community and family connections, which can be enhanced through social media, are linked to improved educational and health outcomes. The confidence that Indigenous young people demonstrate when approaching the use of social media invites its further use, including in arenas where this group may not usually participate, such as in research. Conclusions: Future research could examine ways to minimise the misuse of social media while maximising its positive potential in the lives of Indigenous young people. Future research should also focus on the positive application of social media and showing evidence in health promotion interventions in order to reduce health inequities between Indigenous and non-Indigenous young people. [ABSTRACT FROM AUTHOR]

Abstract Background Given the persistence of Indigenous health inequities across national contexts, many countries have adopted strategies to improve the health of Indigenous peoples. Governmental recognition of the unique health needs of Indigenous populations is necessary for the development of targeted programs and policies to achieve universal health coverage. At the same time, the participation of Indigenous peoples in decision-making and program and policy design helps to ensure that barriers to health services are appropriately addressed and promotes the rights of Indigenous peoples to self-determination. Due to similar patterns of Indigenous health and health determinants across borders, there have been calls for greater global collaboration in this field. However, most international studies on Indigenous health policy link Anglo-settler democracies (Canada, Australia, Aotearoa/New Zealand and the United States), despite these countries representing a small fraction of the world’s Indigenous people. Aim This paper examines national-level policy in Australia, Brazil, Chile and New Zealand in relation to governmental recognition of differential Indigenous health needs and engagement with Indigenous peoples in health. The paper aims to examine how Indigenous health needs and engagement are addressed in national policy frameworks within each of the countries in order to contribute to the understanding of how to develop pro-equity policies within national health care systems. Methods For each country, a review was undertaken of national policies and legislation to support engagement with, and participation of, Indigenous peoples in the identification of their health needs, development of programs and policies to address these needs and which demonstrate governmental recognition of differential Indigenous health needs. Government websites were searched as well as the following databases: Google, OpenGrey, CAB Direct, PubMed, Web of Science and WorldCat. Findings Each of the four countries have adopted international agreements regarding the engagement of Indigenous peoples in health. However, there is significant variation in the extent to which the principles laid out in these agreements are reflected in national policy, legislation and practice. Brazil and New Zealand both have established national policies to facilitate engagement. In contrast, national policy to enable engagement is relatively lacking in Australia and Chile. Australia, Brazil and New Zealand each have significant initiatives and policy structures in place to address Indigenous health. However, in Brazil this is not necessarily reflected in practice and although New Zealand has national policies these have been recently reported as insufficient and, in fact, may be contributing to health inequity for Māori. In comparison to the other three countries, Chile has relatively few national initiatives or policies in place to support Indigenous engagement or recognise the distinct health needs of Indigenous communities. Conclusions The adoption of international policy frameworks forms an important step in ensuring that Indigenous peoples are able to participate in the formation and implementation of health policy and programs. However, without the relevant principles being reflected in national legislature, international agreements hold little weight. At the same time, while a national legislative framework facilitates the engagement of Indigenous peoples, such policy may not necessarily translate into practice. Developing multi-level approaches that improve cohesion between international policy, national policy and practice in Indigenous engagement in health is therefore vital. Given that each of the four countries demonstrate strengths and weaknesses across this causal chain, cross-country policy examination provides guidance on strengthening these links.

Background: Indigenous young people are currently highly overrepresented in the HIV epidemic in Canada, especially in the Prairie Provinces, such as Manitoba. Understanding HIV-vulnerability in Indigenous peoples must begin with understanding that social determinants are intersectional and linked to the historical legacy of European colonization. In this paper findings that detail the influence of the intersectional social determinants on Indigenous people who become infected with HIV in their youth are presented. Methods: The qualitative research design of phenomenology was used as it afforded the opportunity to understand Indigenous young people from their frames of reference and experiences of reality, resulting in a phenomenological understanding of their perspectives and experiences of the early years of living with HIV. A total of 21 Indigenous young people took part open-ended interviews. Results: The stories that the Indigenous young people shared revealed their deeply interconnected social worlds, and how social determinants including abuse, trauma, being part of the child welfare system, and housing and food security were connected throughout various stages of their lives. Such stages included childhood, adolescence and young adulthood (the time of HIV infection), and later adulthood for older participants with the social determinants having multiple influences on their health trajectories. Conclusions: The findings highlight the need for policies and programs that are broadly focused, addressing multiple social determinants together. Overall, there needs to be more emphasis on the multiple social determinants in the life situations of all Indigenous youth. Reducing the health and social disparities in Indigenous youth is key to reducing the number of young Indigenous people diagnosed with HIV. The findings also shed light on the importance of listening to young Indigenous people who have experienced HIV diagnosis and life following diagnosis. [ABSTRACT FROM AUTHOR]

Background: It is well established that Aboriginal and Torres Strait Islander populations face considerable health inequities, exacerbated by poorer healthcare quality. Patient experience is recognised as a major contributing factor to healthcare quality and outcomes, therefore, enriched knowledge of the patient experiences of Aboriginal and Torres Strait Islander populations is critical to redress health inequities. This review synthesises evidence of the healthcare experiences amongst Aboriginal and Torres Strait Islander patients through a metanarrative synthesis of qualitative literature. Methods: A systematic search strategy was developed and applied to six electronic databases between January 2000 and July 2019. Titles and abstracts were screened before applying the inclusion criteria to full text articles. A meta-narrative synthesis was undertaken. Results: Fifty-four publications were identified from four research traditions; each with a unique conceptualisation of patient experience. Three themes emerged that demonstrate Aboriginal and Torres Strait Islander patient experiences are informed by 1) beliefs about wellbeing and healthcare provision, 2) their level of trust in the healthcare system, and 3) individual and community health system interactions. The findings highlight a range of aspects of patient experience that were important to participating Aboriginal and Torres Strait Islanders in the included studies but not captured currently in health system surveys. Conclusion: This review highlights the influence of beliefs about health and wellbeing on the patient experience amongst Aboriginal and Torres Strait Islander populations in the Australian health system. Patient experiences were informed by past experience and their trust in the health system. The different factors influencing patient experience and the gravity of their influence must be considered in current approaches to capturing patient experience data collection methods. Trial registration: PROSPERO (ID: CRD42019134765). [ABSTRACT FROM AUTHOR]

Background: Cancer is the second leading cause of death among Aboriginal and Torres Strait Islander people and their survival once diagnosed with cancer is lower compared to that of other Australians. This highlights the need to improve cancer-related health services for Indigenous Australians although how to achieve this remains unclear. Cancer support groups provide emotional and practical support, foster a sense of community and belonging and can improve health outcomes. However, despite evidence on their positive effects on people affected by cancer, there is scarce information on the function and effectiveness of Indigenous-specific cancer peer-support programs in Australia. Using qualitative data from an evaluation study, this paper explores different understandings of how a cancer support group should operate and the impact of unresolved tensions following the establishment of an Indigenous women cancer peer-support network in a regional town in Western Australia. Methods: Data were collected through semi-structured interviews with 24 participants purposively selected among Indigenous and mainstream healthcare service providers, and group members and clients. Interviews were audiotaped and transcribed verbatim. Transcripts were subjected to inductive thematic analysis. NVivo was used to manage the data and assist in the data analysis. Rigour was enhanced through team member checking, coding validation and peer debriefing. Results: Flexibility and a resistance to formal structuring were at the core of how the group operated. It was acknowledged that the network partly owned its success to its fluid approach; however, most mainstream healthcare service providers believed that a more structured approach was needed for the group to be sustainable. This was seen as acting in opposition to the flexible, organic approach considered necessary to adequately respond to Indigenous women's needs. At the core of these tensions were opposing perspectives on the constructs of ‘structure’ and ‘flexibility' between Indigenous and non-Indigenous participants. Conclusions: Despite the group's achievements, unresolved tensions between opposing perspectives on how a support group should operate negatively impacted on the working relationship between the group and mainstream service providers, and posed a threat to the Network's sustainability. Our results support the need to acknowledge and address different perspectives and world views in order to build strong, effective partnerships between service providers and Indigenous communities. [ABSTRACT FROM AUTHOR]

Background: Health intervention implementation in Aotearoa New Zealand (NZ), as in many countries globally, usually varies by ethnicity. Māori (the Indigenous peoples of Aotearoa) and Pacific peoples are less likely to receive interventions than other ethnic groups, despite experiencing persistent health inequities. This study aimed to develop an equity-focused implementation framework, appropriate for the Aotearoa NZ context, to support the planning and delivery of equitable implementation pathways for health interventions, with the intention of achieving equitable outcomes for Māori, as well as people originating from the Pacific Islands. Methods: A scoping review of the literature to identify existing equity-focused implementation theories, models and frameworks was undertaken. One of these, the Equity-based framework for Implementation Research (EquIR), was selected for adaptation. The adaptation process was undertaken in collaboration with the project's Māori and consumer advisory groups and informed by the expertise of local health equity researchers and stakeholders, as well as the international implementation science literature. Results: The adapted framework's foundation is the principles of Te Tiriti o Waitangi (the written agreement between Māori rangatira (chiefs) and the British Crown), and its focus is whānau (extended family)-centred implementation that meets the health and wellbeing aspirations, priorities and needs of whānau. The implementation pathway comprises four main steps: implementation planning, pathway design, monitoring, and outcomes and evaluation, all with an equity focus. The pathway is underpinned by the core constructs of equitable implementation in Aotearoa NZ: collaborative design, anti-racism, Māori and priority population expertise, cultural safety and values-based. Additionally, the contextual factors impacting implementation, i.e. the social, economic, commercial and political determinants of health, are included. Conclusions: The framework presented in this study is the first equity-focused process-type implementation framework to be adapted for the Aotearoa NZ context. This framework is intended to support and facilitate equity-focused implementation research and health intervention implementation by mainstream health services. [ABSTRACT FROM AUTHOR]

Background: Red River Métis families need access to meaningful and appropriate resources when their children are sick. At the invitation of the Manitoba Métis Federation (MMF) to partner in this research, our aim was to understand Red River Métis parents' experiences and preferences for seeking child health information when their child is acutely ill, to inform the adaptation of existing parent resources. Methods: A qualitative descriptive approach underpinned by a participatory paradigm guided this study. Semi-structured interviews were conducted with 19 Red River Métis parents and Elders via Zoom or telephone. An inductive thematic analysis approach was used to explore patterns and themes across the data. Results: Analysis generated four themes: (1) We're here too; (2) We are not all the same; (3) Finding trustworthy information; and (4) Information needs to be widely available. Red River Métis pride was prominent in the results. Parents provided tangible ways to modify existing parent resources, including adding information on how to access Elders, healers and/or traditional medicines and showing different family structures, transport, living situations, Métis names, and incorporating Métis languages. While most parents reported looking for child health information online, they also stressed the need to provide multiple options, including information sheets, recognizing that parents seek information in different contexts. Parents also emphasized the importance of accessible, safe spaces to find child health information, including local schools, community centres, healthcare organizations and the MMF. Conclusion: There is a lack of child health information created specifically for Red River Métis families. The development of this information can support their information needs and preferences and the ongoing efforts to revitalize Red River Métis culture and language. Study findings will inform the adaptation and dissemination of existing child health resources to ensure they reflect Red River Métis parents' information needs and preferences. This research is a critical step in addressing an identified need for Red River Métis families to have culturally relevant and meaningful child health resources, and in the pursuit of equitable care for all children in Canada. Trial Registration: N/A. [ABSTRACT FROM AUTHOR]

Objective: To evaluate if existing Australian public policy related to screening, diagnosis, treatment and follow up care for breast cancer addresses the needs of and outcomes for Indigenous1 women? Methods: This review of policy employed a modified Delphi method via an online panel of experts (n = 13), who were purposively recruited according to experience and expertise. A series of online meetings and online surveys were used for data collection. The aims of the study were to: Identify all existing and current breast cancer policy in Australia; Analyse the extent to which consideration of Indigenous peoples is included in the development, design and implementation of the policy; and Identify policy gaps and make recommendations as to how they could be addressed. The policies were evaluated using 'A Guide to Evaluation under the Indigenous Evaluation Strategy, 2020'. Results: A list of current breast cancer policies (n = 7) was agreed and analysed. Five draft recommendations to improve breast cancer outcomes for Indigenous women were developed and refined by the panel. Conclusions: Current breast cancer policy in Australia does not address the needs of Indigenous women and requires change to improve outcomes. [ABSTRACT FROM AUTHOR]

Background: Indigenous populations across the world are more likely to suffer from poor health outcomes when compared to other racial and ethnic groups. Although these disparities have many sources, one protective factor that has become increasingly apparent is the continued use and/or revitalization of traditional Indigenous lifeways: Indigenous language in particular. This realist review is aimed at bringing together the literature that addresses effects of language use and revitalization on mental and physical health. Methods: Purposive bibliographic searches on Scopus were conducted to identify relevant publications, further augmented by forward citation chaining. Included publications (qualitative and quantitative) described health outcomes for groups of Indigenous people who either did or did not learn and/or use their ancestral language. The geographical area studied was restricted to the Americas, Australia or New Zealand. Publications that were not written in English, Spanish, French, Portuguese or German were excluded. A realist approach was followed to identify positive, neutral or negative effects of language use and/or acquisition on health, with both qualitative and quantitative measures considered. Results: The bibliographic search yielded a total of 3508 possible publications of which 130 publications were included in the realist analysis. The largest proportion of the outcomes addressed in the studies (62.1%) reported positive effects. Neutral outcomes accounted for 16.6% of the reported effects. Negative effects (21.4%) were often qualified by such issues as possible cultural use of tobacco, testing educational outcomes in a student's second language, and correlation with socioeconomic status (SES), health access, or social determinants of health; it is of note that the positive correlations with language use just as frequently occurred with these issues as the negative correlations did. Conclusions: Language use and revitalization emerge as protective factors in the health of Indigenous populations. Benefits of language programs in tribal and other settings should be considered a cost-effective way of improving outcomes in multiple domains. [ABSTRACT FROM AUTHOR]

Abstract Background The current focus on monitoring health inequalities and the complexity around ethnicity requires careful consideration of how ethnic disparities are measured and presented. This paper aims to determine how inequalities in maternal healthcare by ethnicity change according to different criteria used to classify indigenous populations. Methods Nationally representative demographic surveys from Bolivia, Guatemala, Mexico, and Peru (2008–2016) were used to explore coverage gaps across maternal health care by ethnicity using different criteria. Women were classified as indigenous through self-identification (SI), spoken indigenous language (SIL), or indigenous household (IH). We compared the gaps through measuring coverage ratios (CR) with adjusted Poisson regression models. Results Proportions of indigenous women changed significantly according to the identification criterion (Bolivia:SI-63.1%/SIL-37.7%; Guatemala:SI-49.7%/SIL-28.2%; Peru:SI-34%/SIL-6.3% & Mexico:SI-29.7%/SIL-6.9%). Indigenous in all countries, regardless of their identification, had less coverage. Gaps in care between indigenous and non-indigenous populations changed, for all indicators and countries, depending on the criterion used (e.g., Bolivia CR for contraceptive-use SI = 0.70, SIL = 0.89; Guatemala CR for skilled-birth-attendant SI = 0.77, SIL = 0.59). The heterogeneity persists when the reference groups are modified and compare just to non-indigenous (e.g., Bolivia CR for contraceptive-use under SI = 0.64, SIL = 0.70; Guatemala CR for Skilled-birth-attendant under SI = 0.77, SIL = 0.57). Conclusions The indigenous identification criteria could have an impact on the measurement of inequalities in the coverage of maternal health care. Given the complexity and diversity observed, it is not possible to provide a definitive direction on the best way to define indigenous populations to measure inequalities. In practice, the categorization will depend on the information available. Our results call for greater care in the analysis of ethnicity-based inequalities. A greater understanding on how the indigenous are classified when assessing inequalities by ethnicity can help stakeholders to deliver interventions responsive to the needs of these groups.

Background: The Australian Nurse Family Partnership Program (ANFPP) is an evidence-based, home visiting program that offers health education, guidance, social and emotional support to first-time mothers having Aboriginal and/or Torres Strait Islander (First Nations) babies. The community-controlled sector identified the need for specialised support for first time mothers due to the inequalities in birthing and early childhood outcomes between First Nations' and other babies in Australia. The program is based on the United States' Nurse Family Partnership program which has improved long-term health outcomes and life trajectories for mothers and children. International implementation of the Nurse Family Partnership program has identified interagency service integration as key to program recruitment, retention, and efficacy. How the ANFPP integrates with other services in an Australian urban setting and how to improve this is not yet known. Our research explores the barriers and enablers to interagency service integration for the Australian Nurse Family Partnership Program ANFPP in an urban setting. Methods: A qualitative study using individual and group interviews. Purposive and snowball sampling was used to recruit clients, staff (internal and external to the program), Elders and family members. Interviews were conducted using a culturally appropriate 'yarning' method with clients, families and Elders and semi-structured interview guide for staff. Interviews were audio-recorded and transcribed prior to reflexive thematic analysis. Results: Seventy-six participants were interviewed: 26 clients, 47 staff and 3 Elders/family members. Three themes were identified as barriers and three as enablers. Barriers: 1) confusion around program scope, 2) duplication of care, and 3) tensions over 'ownership' of clients. Enablers (existing and potential): 1) knowledge and promotion of the program; 2) cultural safety; and 3) case coordination, co-location and partnership forums. Conclusion: Effective service integration is essential to maximise access and acceptability of the ANFPP; we provide practical recommendations to improve service integration in this context. [ABSTRACT FROM AUTHOR]

Background: The United Nations Convention on the Rights of the Child confirms a child's right to adequate food, and to the highest attainable standard of health. For indigenous children, these rights are also recognised in the UN Declaration on the Rights of Indigenous Peoples. However, Indigenous children endure higher rates of obesity and related health conditions than non-indigenous children, including in Aotearoa New Zealand (NZ). For indigenous tamariki (Māori children) in NZ, high levels of obesity are interconnected with high rates of food insecurity. Therefore there is a need for action. This study aimed to investigate policy options that would safeguard the rights of indigenous children to healthy food. We explored with key stakeholder's policy options to ensure the rights of indigenous children to healthy food, through a case study of the rights of tamariki. Methods: Interviews were conducted with 15 key stakeholders, with experience in research, development or delivery of policies to safeguard the rights of tamariki to healthy food. Iterative thematic analysis of the transcripts identified both deductive themes informed by Kaupapa Māori theory and literature on rights-based approaches and inductive themes from the interviews. Results: The analysis suggests that to ensure the right to adequate food and to healthy food availability for tamariki, there needs to be: a comprehensive policy response that supports children's rights; an end to child poverty; food provision and food policy in schools; local government policy to promote healthy food availability; and stronger Māori voices and values in decision-making. Conclusions: The right to food for indigenous children, is linked to political and economic systems that are an outcome of colonisation. A decolonising approach where Māori voices and values are central within NZ policies and policy-making processes is needed. Given the importance of food to health, a broad policy approach from the NZ government to ensure the right to adequate food is urgent. This includes economic policies to end child poverty and specific strategies such as food provision and food policy in schools. The role of Iwi (tribes) and local governments needs to be further explored if we are to improve the right to adequate food within regions of NZ. [ABSTRACT FROM AUTHOR]

Background: Indigenous populations have remained strong and resilient in maintaining their unique culture and values, despite centuries of colonial oppression. Unfortunately, a consequential result of facing years of adversity has led Indigenous populations to experience a disproportionate level of poorer health outcomes compared to non-Indigenous populations. Specifically, the rate of Indigenous chronic disease prevalence has significantly increased in the last decade. Many of the unique issues Indigenous populations experience are deeply rooted in their colonial history and the intergenerational traumas that has subsequently impacted their physical, mental, emotional and spiritual well-being. With this, to better improve Indigenous health outcomes, understanding the local context of their challenges is key. Studies have begun to use modes of community engagement to initiate Indigenous partnerships and design chronic disease-based interventions. However, with the lack of a methodological guideline regarding the appropriate level of community engagement to be used, there is concern that many interventions will continue to fall short in meeting community needs. Objective: The objective of this study was to investigate the how various community engagement strategies have been used to design and/or implement interventions for Indigenous populations with chronic disease. Methods: A scoping review guided by the methods outlined by Arksey and O'Malley was conducted. A comprehensive search was completed by two reviewers in five electronic databases using keywords related to community engagement, Indigenous health and chronic disease. Studies were reviewed using a descriptive-analytical narrative method and data was categorized into thematic groups reflective of the main findings. Results: We identified 23 articles that met the criteria for this scoping review. The majority of the studies included the use a participatory research model and the procurement of study approval. However, despite the claimed use of participatory research methods, only 6 studies had involved community members to identify the area of priority and only five had utilized Indigenous interview styles to promote meaningful feedback. Adapting for the local cultural context and the inclusion of community outreach were identified as the key themes from this review. Conclusion: Many studies have begun to adopt community engagement strategies to better meet the needs of Indigenous Peoples. With the lack of a clear guideline to approach Indigenous-based participatory research, we recommend that researchers focus on 1) building partnerships, 2) obtaining study approval and 3) adapting interventions to the local context. [ABSTRACT FROM AUTHOR]

Background: People with autism spectrum disorder (ASD) face many psychosocial challenges throughout life, highlighting the need for programs and resources promoting psychosocial wellbeing. Indigenous peoples with ASD and/or other neurodevelopmental disorders must overcome cultural and social barriers to access such supports. This study aimed to identify psychosocial programs and resources developed world-wide for this population by systematically reviewing research evaluating programs aiming to promote the psychosocial wellbeing of this population and/or their caregivers; and collating and reviewing resources developed to promote their psychosocial wellbeing. Methods: Searches were last conducted in December 2019. The systematic review searched 28 electronic databases, and 25 electronic databases were searched for resources promoting psychosocial wellbeing. Additional published and unpublished studies were identified from relevant reviews, authors of eligible articles, and experts working in Indigenous Health. Articles and resources were screened for inclusion using pre-defined criteria. Articles included in the systematic review were assessed for quality using the Mixed Methods Assessment Tool. The diversity and paucity of outcomes reported precluded pooling of study findings for meta-analysis. Results: Seven articles situated in the USA (2), Canada (3) and Australia (2); and eleven resources developed in Australia (9), Canada (1) and New Zealand (1) met inclusion criteria. All articles showed some promising findings for improving psychosocial wellbeing for Indigenous children with ASD and/or another neurodevelopmental disorder, and 5 of 7 evaluated the cultural adaptation of an existing evidence-based program for an Indigenous population. However, methodological quality was moderate or low (57% and 43% of articles respectively) and no studies had adult participants. The psychosocial wellbeing supports provided by the 11 resources included psychoeducation, community support, and services/workshops. Conclusions: Despite the paucity of research and resources found, important exemplars demonstrate that existing programs can be adapted to support Indigenous people with ASD and other neurodevelopmental disorders. While future policy should endeavour to facilitate Indigenous people's access to support services, and encourage researchers to develop and evaluate programs promoting psychosocial wellbeing for this population, given complexities of designing and evaluating new programs, careful and appropriate cultural adaptations of existing evidence-based programs would increase feasibility of ongoing research without compromising outcomes. [ABSTRACT FROM AUTHOR]

Backgrounds: An intercultural society facilitates equitable and respectful interrelations. Knowing and understanding each other's sociocultural and linguitic contexts is a prerequisite for an intercultural society. This study explores the concepts of health and illness among healers of indigenous ethnicities in Southern Ecuador. Methods: A qualitative observational study with eleven focus groups was conducted in three locations in Southern Ecuador; a total of 110 participants the Shuar, Kichwa and Mestizo ethnic groups were included. A phenomenological and hermeneutic analysis was conducted. Results: Fourteen main subtopics around of two predefined themes, i.e., "Health" and "Illness" were identified: 1) four bodies, 2) religiosity, 3) health as a good diet, 4) health as god's blessing or a gift, 5) health as balance/ harmony, 6) health as community and social welfare, 7) health as potentiality or a skill, 8) health as peacefulness, 9) heath as individual will, 10) illness as an imbalance, 11) illness as bad energy, 12) illness as a bad diet, 13) illness as suffering or worry, and 14) illness from God, Nature and People illness. By analysing all the topics' and subtopics' narratives, a health and illness definition was developed. The principal evidence for this new framework is the presence of interculturality as a horizontal axis in health. The indigenous perspective of health and illness focus on a balance between 4 bodies: the physical, spiritual, social and mental bodies. Additionally, "good health" is obtained through of the good diet and balanced/harmony. Conclusion: Indigenous healers in Southern Ecuador have views on health and illness that differ from the Western biomedical model of care. These different views must be recognized and valued in order to build an intercultural (health) system that empowers both ancestral and modern medical knowledge and healing. [ABSTRACT FROM AUTHOR]

Background: Colonization continues in Australia, sustained through institutional and systemic racism. Targeted discrimination and intergenerational trauma have undermined the health and wellbeing of Australia's Aboriginal and Torres Strait Islander population, leading to significantly poorer health status, social impoverishment and inequity resulting in the over-representation of Aboriginal people in Australian prisons. Despite adoption of the 'equal treatment' principle, on entering prison in Australia entitlements to the national universal healthcare system are revoked and Aboriginal people lose access to health services modelled on Aboriginal concepts of culturally safe healthcare available in the community. Incarcerated Aboriginal women experience poorer health outcomes than incarcerated non-Indigenous women and Aboriginal men, yet little is known about their experiences of accessing healthcare. We report the findings of the largest qualitative study with incarcerated Aboriginal women in New South Wales (NSW) Australia in over 15 years. Methods: We employed a decolonizing research methodology, 'community collaborative participatory action research', involving consultation with Aboriginal communities prior to the study and establishment of a Project Advisory Group (PAG) of community expert Aboriginal women to guide the project. Forty-three semi-structured interviews were conducted in 2013 with Aboriginal women in urban and regional prisons in NSW. We applied a grounded theory approach for the data analysis with guidance from the PAG. Results: Whilst Aboriginal women reported positive and negative experiences of prison healthcare, the custodial system created numerous barriers to accessing healthcare. Aboriginal women experienced institutional racism and discrimination in the form of not being listened to, stereotyping, and inequitable healthcare compared with non-Indigenous women in prison and the community. Conclusions: 'Equal treatment' is an inappropriate strategy for providing equitable healthcare, which is required because incarcerated Aboriginal women experience significantly poorer health. Taking a decolonizing approach, we unpack and demonstrate the systems level changes needed to make health and justice agencies culturally relevant and safe. This requires further acknowledgment of the oppressive transgenerational effects of ongoing colonial policy, a true embracing of diversity of worldviews, and critically the integration of Aboriginal concepts of health at all organizational levels to uphold Aboriginal women's rights to culturally safe healthcare in prison and the community. [ABSTRACT FROM AUTHOR]

Background: In recent decades, financial investment has been made in health-related programs and services to overcome inequities and improve Indigenous people's wellbeing in Australia and New Zealand. Despite policies aiming to 'close the gap', limited evaluation evidence has informed evidence-based policy and practice. Indigenous leaders have called for evaluation stakeholders to align their practices with Indigenous approaches. Methods: This study aimed to strengthen culturally safe evaluation practice in Indigenous settings by engaging evaluation stakeholders, in both countries, in a participatory concept mapping study. Concept maps for each country were generated from multi-dimensional scaling and hierarchical cluster analysis. Results: The 12-cluster Australia map identifies four cluster regions: An Evaluation Approach that Honours Community; Respect and Reciprocity; Core Heart of the Evaluation; and Cultural Integrity of the Evaluation. The 11-cluster New Zealand map identifies four cluster regions: Authentic Evaluation Practice; Building Māori Evaluation Expertise; Integrity in Māori Evaluation; and Putting Community First. Both maps highlight the importance of cultural integrity in evaluation. Differences include the distinctiveness of the 'Respecting Language Protocols' concept in the Australia map in contrast to language being embedded within the cluster of 'Knowing Yourself as an Evaluator in a Māori Evaluation Context' in the New Zealand map. Participant ratings highlight the importance of all clusters with some relatively more difficult to achieve, in practice. Notably, the 'Funding Responsive to Community Needs and Priorities' and 'Translating Evaluation Findings to Benefit Community' clusters were rated the least achievable, in Australia. The 'Conduct of the Evaluation' and the 'Prioritising Māori Interests' clusters were rated as least achievable in New Zealand. In both countries, clusters of strategies related to commissioning were deemed least achievable. Conclusions: The results suggest that the commissioning of evaluation is crucial as it sets the stage for whether evaluations: reflect Indigenous interests, are planned in ways that align with Indigenous ways of working and are translated to benefit Indigenous communities Identified strategies align with health promotion principles and relational accountability values of Indigenous approaches to research. These findings may be relevant to the commissioning and conduct of Indigenous health program evaluations in developed nations. [ABSTRACT FROM AUTHOR]

Abstract Background Indigenous young people are currently highly overrepresented in the HIV epidemic in Canada, especially in the Prairie Provinces, such as Manitoba. Understanding HIV-vulnerability in Indigenous peoples must begin with understanding that social determinants are intersectional and linked to the historical legacy of European colonization. In this paper findings that detail the influence of the intersectional social determinants on Indigenous people who become infected with HIV in their youth are presented. Methods The qualitative research design of phenomenology was used as it afforded the opportunity to understand Indigenous young people from their frames of reference and experiences of reality, resulting in a phenomenological understanding of their perspectives and experiences of the early years of living with HIV. A total of 21 Indigenous young people took part open-ended interviews. Results The stories that the Indigenous young people shared revealed their deeply interconnected social worlds, and how social determinants including abuse, trauma, being part of the child welfare system, and housing and food security were connected throughout various stages of their lives. Such stages included childhood, adolescence and young adulthood (the time of HIV infection), and later adulthood for older participants with the social determinants having multiple influences on their health trajectories. Conclusions The findings highlight the need for policies and programs that are broadly focused, addressing multiple social determinants together. Overall, there needs to be more emphasis on the multiple social determinants in the life situations of all Indigenous youth. Reducing the health and social disparities in Indigenous youth is key to reducing the number of young Indigenous people diagnosed with HIV. The findings also shed light on the importance of listening to young Indigenous people who have experienced HIV diagnosis and life following diagnosis.

Abstract Introduction Healthcare organisations serve clients from diverse Indigenous and other ethnic and racial groups on a daily basis, and require appropriate client-centred systems and services for provision of optimal healthcare. Despite advocacy for systems-level approaches to cultural competence, the primary focus in the literature remains on competency strategies aimed at health promotion initiatives, workforce development and student education. This paper aims to bridge the gap in available evidence about systems approaches to cultural competence by systematically mapping key concepts, types of evidence, and gaps in research. Methods A literature search was completed as part of a larger systematic search of evaluations and measures of cultural competence interventions in health care in Canada, the United States, Australia and New Zealand. Seventeen peer-reviewed databases, 13 websites and clearinghouses, and 11 literature reviews were searched from 2002 to 2015. Overall, 109 studies were found, with 15 evaluating systems-level interventions or describing measurements. Thematic analysis was used to identify key implementation principles, intervention strategies and outcomes reported. Results Twelve intervention and three measurement studies met our inclusion criteria. Key principles for implementing systems approaches were: user engagement, organisational readiness, and delivery across multiple sites. Two key types of intervention strategies to embed cultural competence within health systems were: audit and quality improvement approaches and service-level policies or strategies. Outcomes were found for organisational systems, the client/practitioner encounter, health, and at national policy level. Discussion and implications We could not determine the overall effectiveness of systems-level interventions to reform health systems because interventions were context-specific, there were too few comparative studies and studies did not use the same outcome measures. However, examined together, the intervention and measurement principles, strategies and outcomes provide a preliminary framework for implementation and evaluation of systems-level interventions to improve cultural competence. Identified gaps in the literature included a need for cost and effectiveness studies of systems approaches and explication of the effects of cultural competence on client experience. Further research is needed to explore the extent to which cultural competence improves health outcomes and reduces ethnic and racially-based healthcare disparities.

Objectives: To (1) gain an understanding of current trajectories of Aboriginal young people through the mental health care system in Australia; (2) summarize what mental health care pathways have been developed or evaluated to guide mental health care delivery for Aboriginal young people; and (3) identify barriers and facilitators to the adoption of effective mental health care pathways for Aboriginal young people. Methods: Databases, including, AMED, Embase, Global Health, Health and Psychosocial Instruments, Healthstar, MEDLINE, PsychINFO via Ovid, CINAHL via EBSCO, The Cochrane Library, Indigenous Collections, Informit and Health Systems Evidence, were searched to identify evidence concerning mental health service delivery for Aboriginal young people in a primary care setting. Results: We did not identify any reports or publications explicitly describing the current trajectories of Aboriginal young people through the mental health care system in Australia. Furthermore, we were unable to locate any mental health-related treatment pathways which had been explicitly developed or modified to meet the needs of Aboriginal young people. The use of appropriate assessment tools, engagement of family and community, flexibility, and central coordination have been identified in the literature as potential facilitators of culturally appropriate mental health service delivery for Aboriginal children and adolescents. Conclusions: Aboriginal children and adolescents may face additional difficulties navigating the mental health care system in Australia due to complex socio-cultural factors and the dearth of culturally appropriate and effective mental-health related treatment pathways. Additional research regarding (1) practice trends in Aboriginal settings and (2) how Aboriginal child and adolescent mental health can be improved is urgently needed to inform clinical practice and improve mental health service access and outcomes for Aboriginal young people in Australia. [ABSTRACT FROM AUTHOR]

Background: Aboriginal and Torres Strait Islander people have higher rates of chronic disease and a lower life expectancy than non-Indigenous Australians. In non-urban areas these health disparities are even larger. The aim of this qualitative study was to explore perceived barriers and enablers to attending an eight-week physical activity program in a rural and regional setting which aimed to improve health outcomes, but had a low attendance rate. Methods: Thirty-four Indigenous Australians participated in the intervention from the rural (n = 12) and the regional (n = 22) community. Qualitative semi-structured individual interviews were conducted at the follow-up health assessments with 12 participants. A thematic network analysis was undertaken to examine the barriers and enablers to participation in the program. Results: Overall, there were positive attitudes to, and high levels of motivation towards, the physical activity program. Enablers to participation were the inclusion of family members, no financial cost and a good relationship with the principal investigator, which was strengthened by the community-based participatory approach to the program design. Barriers to program attendance were mostly beyond the control of the individuals, such as 'sorry business', needing to travel away from the community and lack of community infrastructure. Conclusions: More consideration is needed prior to implementation of programs to understand how community- specific barriers and enablers will affect attendance to the program. Trial registration: ACTRN12616000497404. Registered 18 April 2016. [ABSTRACT FROM AUTHOR]

Background: A growing body of literature highlights that racial discrimination has negative impacts on child health, although most studies have been limited to an examination of direct forms of racism using cross-sectional data. We aim to provide further insights on the impact of early exposure to racism on child health using longitudinal data among Indigenous children in Australia and multiple indicators of racial discrimination. Methods: We used data on 1239 Indigenous children aged 5-10 years from Waves 1-6 (2008-2013) of Footprints in Time, a longitudinal study of Indigenous children across Australia. We examined associations between three dimensions of carer-reported racial discrimination (measuring the direct experiences of children and vicarious exposure by their primary carer and family) and a range of physical and mental health outcomes. Analysis was conducted using multivariate logistic regression within a multilevel framework. Results: Two-fifths (40%) of primary carers, 45% of families and 14% of Indigenous children aged 5-10 years were reported to have experienced racial discrimination at some point in time, with 28-40% of these experiencing it persistently (reported at multiple time points). Primary carer and child experiences of racial discrimination were each associated with poor child mental health status (high risk of clinically significant emotional or behavioural difficulties), sleep difficulties, obesity and asthma, but not with child general health or injury. Children exposed to persistent vicarious racial discrimination were more likely to have sleep difficulties and asthma in multivariate models than those with a time-limited exposure. Conclusions: The findings indicate that direct and persistent vicarious racial discrimination are detrimental to the physical and mental health of Indigenous children in Australia, and suggest that prolonged and more frequent exposure to racial discrimination that starts in the early lifecourse can impact on multiple domains of health in later life. Tackling and reducing racism should be an integral part of policy and intervention aimed at improving the health of Australian Indigenous children and thereby reducing health disparities between Indigenous and non-Indigenous children. [ABSTRACT FROM AUTHOR]

Background: Wellbeing has been difficult to understand, measure and strengthen for Aboriginal people in remote Australia. Part of the challenge has been genuinely involving community members and incorporating their values and priorities into assessment and policy. Taking a 'shared space' collaborative approach between remote Aboriginal communities, governments and scientists, we merged Aboriginal knowledge with western science -- by bringing together stories and numbers. This research aims to statistically validate the holistic Interplay Wellbeing Framework and Survey that bring together Aboriginal-identified priorities of culture, empowerment and community with government priorities including education, employment and health. Method: Quantitative survey data were collected from a cohort of 842 Aboriginal people aged 15-34 years, recruited from four different Aboriginal communities in remote Australia. Aboriginal community researchers designed and administered the survey. Results: Structural equation modeling showed good fit statistics (χ/df = 2.69, CFI = 0.95 and RMSEA = 0.045) confirming the holistic nature of the Interplay Wellbeing Framework. The strongest direct impacts on wellbeing were 'social and emotional wellbeing' (r = 0.23; p < 0.001), 'English literacy and numeracy' (r = 0.15; p < 0.001), 'Aboriginal literacy' (r = 0.14; p < 0.001), 'substances' (lack thereof; r = 0.13; p = 0.003), 'work' (r = 0.12; p = 0.02) and 'community' (r = 0.08; p = 0.05). Correlation analyses suggested cultural factors have indirect impacts on wellbeing, such as through Aboriginal literacy. All cultural variables correlated highly with each other, and with empowerment and community. Empowerment also correlated highly with all education and work variables. 'Substances' (lack thereof) was linked with positive outcomes across culture, education and work. Specific interrelationships will be explored in detail separately. Conclusion: The Interplay Wellbeing Framework and Survey were statistically validated as a collaborative approach to assessing wellbeing that is inclusive of other cultural worldviews, values and practices. New community-derived social and cultural indicators were established, contributing valuable insight to psychometric assessment across cultures. These analyses confirm that culture, empowerment and community play key roles in the interplay with education, employment and health, as part of a holistic and quantifiable system of wellbeing. This research supports the holistic concept of wellbeing confirming that everything is interrelated and needs to be considered at the 'whole of system' level in policy approaches. [ABSTRACT FROM AUTHOR]