Evidence Review of Indigenous Culture for Health and Wellbeing

Abstract

There is growing evidence that the cultures of Indigenous peoples influence their health and wellbeing. We reviewed articles published between 1997 and 2017 that studied the relationship between culture, and health and wellbeing outcomes, and used an adapted version of the Agency of Healthcare Research Quality Framework to determine their strength of evidence. We examined the literature grouped by six cultural domains: country and caring for country, knowledge and beliefs, language, self-determination, family and kinship, and cultural expression. Seventy-two publications were included in the review, focusing on populations from Australia, Canada, the United States, and New Zealand.

Across the literature there were conceptual variations in defining and measuring culture, and in the comparison of differing social constructs across Indigenous groups. The literature largely report that culture is significantly and positively associated with physical health, social and emotional wellbeing, and reduces risk-taking behaviours. The majority of publications presented evidence on the impact that culture, or culturally-based interventions, have on social and emotional wellbeing outcomes. The strength of evidence from most publications was assessed as moderate or low quality, and was limited by a lack of reliable and valid measures, population level studies, and longitudinal studies. Cultural domains including language, cultural expression and connection to country were more likely to be reported in quantitative studies, whereas cultural domains of knowledge, beliefs, kinship, and family were more likely to be reported using qualitative methods. Those studies that used mixed-methods approaches were more likely to be assessed as high or moderate quality. This review encourages future research to consider adopting mixed-methods approaches to investigate the complex, causal pathways through which culture influences health and wellbeing for Indigenous populations.

Full text

The International Journal of
Health, Wellness, and
Society
Evidence Review of Indigenous Culture for
Health and Wellbeing
SARAH BOURKE, ALYSON WRIGHT, JILL GUTHRIE,
LACHLAN RUSSELL, TERRY DUNBAR, AND RAYMOND LOVETT
HE ALTH AN DSO CIET Y.COM
VOLUME 8 ISSUE 4
________________________________________________

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Evidence Review of Indigenous Culture for
Health and Wellbeing
Sarah Bourke*, University of Oxford, United Kingdom
Alyson Wright*,1Australian National University, Australia
Jill Guthrie, Australian National University, Australia
Lachlan Russell, Australian National University, Australia
Terry Dunbar, Adelaide University, Australia
Raymond Lovett, Australian National University, Australia
Abstract: There is growing evidence that the cultures of Indigenous peoples influence their health and wellbeing. We
reviewed articles published between 1997 and 2017 that studied the relationship between culture, and health and
wellbeing outcomes, and used an adapted version of the Agency of Healthcare Research Quality Framework to determine
their strength of evidence. We examined the literature grouped by six cultural domains: country and caring for country,
knowledge and beliefs, language, self-determination, family and kinship, and cultural expression. Seventy-two
publications were included in the review, focusing on populations from Australia, Canada, the United States, and New
Zealand. Across the literature there were conceptual variations in defining and measuring culture, and in the comparison
of differing social constructs across Indigenous groups. The literature largely report that culture is significantly and
positively associated with physical health, social and emotional wellbeing, and reduces risk-taking behaviours. The
majority of publications presented evidence on the impact that culture, or culturally-based interventions, have on social
and emotional wellbeing outcomes. The strength of evidence from most publications was assessed as moderate or low
quality, and was limited by a lack of reliable and valid measures, population level studies, and longitudinal studies.
Cultural domains including language, cultural expression and connection to country were more likely to be reported in
quantitative studies, whereas cultural domains of knowledge, beliefs, kinship, and family were more likely to be reported
using qualitative methods. Those studies that used mixed-methods approaches were more likely to be assessed as high or
moderate quality. This review encourages future research to consider adopting mixed-methods approaches to investigate
the complex, causal pathways through which culture influences health and wellbeing for Indigenous populations.
Keywords: Culture, Health, Wellbeing, Indigenous, Aboriginal and Torres Strait Islander Peoples,
Evidence Review, Systematic Review
Background
here is increasing recognition that the cultures of Indigenous peoples worldwide has an
important influence on their health and wellbeing (Burgess et al. 2008; Burgess et al.
2009; Chandler and Lalonde 1998; 2008, Chandler et al. 2003; Dockery 2009, 2011;
Hallett, Chandler, and Lalonde 2007). In Australia, this evidence sits alongside the long-term and
continued call from Aboriginal and Torres Strait Islander peoples for the freedom to maintain,
transfer, and revitalise their cultures. Further, there is growing community demand for public
health practitioners and researchers to genuinely engage with Indigenous concepts of health, and
to ensure that research efforts amount to translatable health benefits for Indigenous people. Ms
June Oscar AO, Aboriginal and Torres Strait Islander Social Justice Commissioner, recently
asserted that “one of the pillars of our good health is the strength of our culture and our
connection to our culture, our land, and our old ways” (Oscar 2017, 1).
Similarly to other Indigenous peoples, Aboriginal and Torres Strait Islander peoples in
Australia define health as holistic. This encompasses the spiritual, social, and physical aspects of
* Joint first authors
1 Corresponding Author: Alyson Wright, Florey Building 54 Mills Road, National Centre for Epidemiology and
Population Health, Research School of Population Health, Australian National University, Acton, Canberra, ACT, 2600,
Australia. email: alyson.wright@anu.edu.au
T
The International Journal of Health, Wellness, and Society
Volume 8, Issue 4, 2018, http://healthandsociety.com
© Common Ground Research Networks, Sarah Bourke, Alyson Wright, Jill Guthrie, Lachlan
Russell, Terry Dunbar, Raymond Lovett, Some Rights Reserved (CC BY-NC-ND 4.0).
Permissions: support@cgnetworks.org.
ISSN: 2156-8960 (Print), ISSN: 2156-9053 (Online)
http://doi.org/10.18848/2156-8960/CGP/v08i04/11-27 (Article)

THE INTERNATIONAL JOURNAL OF HEALTH, WELLNESS, AND SOCIETY
a person’s wellbeing, and extends beyond a biomedical description of health (Boddington and
Räisänen 2009). This broad definition attempts to encapsulate an individual’s wellbeing as
intrinsically connected to their environment, community and family (Brady, Kunitz, and Nash
1997). Such explanations and conceptualisations are found in other Indigenous populations
(Beatty and Weber-Beeds 2013; Howell et al. 2016; Mowbray 2007; Smylie and Anderson
2006). As such, this review uses a deliberately wide scope to capture the diversity and breadth in
the methods and ways of defining health and wellbeing, and in examining its interaction with
aspects of Indigenous culture.
Using the holistic definition of health, this article reviews the evidence that describes,
measures, and/or analyses the relationships between culture and Indigenous peoples’ health and
wellbeing, inclusive of literature published between 1997 and 2017. The review aims to examine
their strength of evidence, to describe the studies, and to explore the variety of evidence from
published sources. Secondly, it investigates what cultural characteristics have been studied within
this evidence. This allows the reviewers the opportunity to answer three pertinent and interrelated
research questions:
1. What does the evidence indicate is the relationship of culture to health and
wellbeing outcomes?
2. What is the quality of evidence available? and,
3. What methods are used to explore cultural domains?
Method
Study Inclusion and Exclusion Criteria
The review analysed published papers and reports on the influence or association between culture
and health and wellbeing outcomes. The review focused solely on evidence specific to
Indigenous cultures, including Aboriginal and Torres Strait Islander peoples from within
Australia, and other Indigenous communities worldwide. Inclusion and exclusion criteria were
used in assessing the relevance of sources included in the review.
Inclusion criteria were:
1. Published material, including peer reviewed journal articles and grey literature
reports.
2. The articles and reports that reported empirical evidence, study, or review of
Indigenous culture and health and wellbeing.
3. Published material between 1997 and 2017.
4. English language only.
Exclusion criteria were:
1. Conference presentations.
2. Newspapers, journal perspectives, non-original research, or editorial articles.
3. Full-text unavailable.
4. Perspective articles and opinion pieces that did include empirical research.
5. Articles that presented on racism and cultural safety in healthcare practices. These
articles were captured in the literature searches and were excluded on the basis that
they did not specifically study culture, but rather people’s experiences due to their
cultural background.
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BOURKE AND WRIGHT ET AL.: EVIDENCE REVIEW OF INDIGENOUS CULTURE FOR HEALTH
Search Strategy
Electronic databases included in the literature search were: LitSearch (Pubmed), Web of Science
and Proquest, and Scopus. A further snowball and hand search based on the reference list of
found articles was undertaken. Based on knowledge and preliminary investigations, a list of
primary search terms was developed. Targeted search strings were used to assess evidence about
the cultural determinants of health and wellbeing outcomes in peer-reviewed and grey literature.
When additional key terms emerged during the initial review of articles, then these terms were
added to the search strings.
The final string search was: (Aborigine OR Aboriginal OR Indigenous OR Koori OR First
Nation OR Metis OR Maori OR Sami OR Inuit) AND (culture OR cultural OR country OR
identity OR agency OR self-determination OR empowerment OR fate control OR respect OR
cultural continuity OR language OR ceremony OR ritual OR spirituality) AND (social wellbeing
OR emotional wellbeing OR social and emotional wellbeing OR health OR wellbeing).
Evidence Extraction and Assessment of Evidence Quality
Two assessors (SB, AW) appraised each identified publication against the review criteria
independently, with final checks done on all those which were difficult to categorise by one
assessor (AW). If a publication failed to meet any of the inclusion criteria, it was excluded. A
group of three assessors (AW, SB, LR) extracted the data; this included study design, location,
year, and key findings. These assessors (AW, SB, LR) also analysed the strength of evidence in
each publication using a modified version of the Agency of Healthcare Research and Quality
Framework (AHRQ) (Berkman et al. 2015).
Some adaptation of the AHRQ Framework was necessary because the review included not
only interventions, but also descriptive studies, analytical studies and other observational studies.
In the context of examining relationships of culture, wellbeing and health specific to Indigenous
peoples, another factor—Indigenous viewpoint—was added. The AHRQ framework was initially
thought to be appropriate because the flexibility in assessment allowed for the inclusion of
studies from diverse sources with differing methods and approaches. It was important to include
as much literature as possible, and we did not want to exclude evidence because it was not in a
certain format. Using the AHRQ framework, the following factors were assessed: study
limitations, directness, consistency, precision and reporting bias. In circumstances of initial
differences in assessment, discussions were had with the at least two teams members of the
assessment team (AW with RL or SB or LR) until consensus was reached.
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Table 1: Factors Assessed in the Evidence Review to Determine Strength of Evidence
Definition Assessment/Coded
Indigenous
Viewpoint
Engagement with Indigenous people is a key factor in the
study. Research-led or in partnership with Indigenous
communities is considered to include Indigenous
constructs, worldviews and stand points.
Yes
No
Study
limitations
Study design (good internal validity) and conduct is
appropriate for the research question. The limitations are
minimised in the process. There is an assessment of
limitations and the overarching findings reported provide
consideration of the study limitations.
High
Medium
Low
Directness
The study provides direct measures of association between
variables, and the variables assessed are independent.
Indirectness suggests that more than one form of evidence
is required to link outcomes.
Direct
Indirect
Consistency
There is little variability from other studies. The magnitude
and direction of the results is similar. The study is
reproducible and results are reliable.
Consistent
Unknown
Inconsistent
Precision
The study measures considered are appropriate and
standard or valid. The work demonstrates significance
through one of the following ways: repetition in themes,
effect size or p values.
Precise
Imprecise
Reporting bias
Selectively publishing or reporting research findings based
on favourability of direction or magnitude of effect; can
include study publication bias, selective outcome reporting
bias, and selective analysis outcome bias.
Not suspected
Suspected
Undetected
Source: Adapted from Bergman et al. 2015
The evidence was graded as:
High: Very confident that the estimate of the effect of the relationship between cultural domains
and health and wellbeing outcomes is close to the true effect. The body of evidence has few or no
deficiencies. We believe that the findings are stable, that is, another study would not change the
conclusions.
Moderate: Moderately confident that the estimate of the effect lies close to the true effect for this
outcome. The body of evidence has some deficiencies. We believe that the findings are likely to
be stable, but some doubt remains.
Low: Limited confidence that the estimate of effect lies close to the true effect for this outcome.
The body of evidence has major or numerous deficiencies (or both). We believe that additional
evidence is needed before concluding either that the findings are stable or that the estimate of
effect lies close to the true effect.
Identification and Examination of Cultural Domains
All publications were also assessed by which cultural domains were covered in each of the
studies. The cultural domains were defined in work undertaken in a parallel research synthesis
(Salmon et al. forthcoming). The cultural domains included country, knowledges and beliefs,
language, self-determination, family and kinship, and cultural expression (see Table 2 for
descriptions). Two assessors (AW, RL) independently assessed the publications to determine
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BOURKE AND WRIGHT ET AL.: EVIDENCE REVIEW OF INDIGENOUS CULTURE FOR HEALTH
which cultural domains were studied. Where there were differences in initial opinion, each item
was discussed until consensus was reached by the assessors.
Table 2: Conceptual Meanings of the Cultural Domains for Aboriginal and
Torres Strait Islander Perspectives’ Used To Assess Publications
Cultural domain Conceptualisation
Country and caring for country
Country and connection to country is closely related to
identity, attachment with the physical environment, and
a sense of belonging. In Indigenous cultures, people
have both physical and spiritual relationships and
responsibilities to look after and maintain country. This
in turn is suggested to provide nurturing and
empowerment to that individual, family and community.
Knowledge and beliefs
Knowledge and belief systems include concepts of
relational identity, spirituality and within group variation
on cultural traditions. Concepts and experiences of
spirituality stem from The Dreaming (creation) and
include how these are passed on various mediums (art,
songs and ceremony or corroboree). It also incorporates
elements of healing, traditional medicines and gendered
knowledge systems and practices.
Language
Indigenous verbal, written and body language is
conceptualised as a vehicle for expressing culture and
communicating it to others, and transmitting cultural
knowledge to the next generation.
Self-determination
Self-determination is contextualised as leading, or at a
minimum, involvement in decision making at the
individual, family, community, organisational and
political levels. It is also contextualised as how
Indigenous peoples do business and involves power and
influence. It is generally considered as a collective form
of decision-making.
Family and kinship
Identity is not only connected to genetics, but predicated
upon descent and social relationships. Kinship includes
knowing and being part of the community and the
perception of oneself. Indigenous society is constructed
around community, and within strong kinship and family
ties. Being a part of the community may entail various
responsibilities and obligations that confirm and
reinforce membership and belonging. This may include
obligations to extended family, responsibilities to be
involved and active in various community functions,
initiatives, and political issues.
Cultural expression
Cultural expression is conceptualised as actions taken to
express attitudes, beliefs, customs and norms.
Expression can often take the form of artefacts, symbols,
dances, songs, genders and age roles, art and ceremony,
storytelling, use of language, family relations, sharing of
food and celebrations, and representation of values.
Source: Adapted from Salmon et al. forthcoming
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Results
Search Results
A total of 11,041 articles were identified during database searches and from the reference lists of
these articles. After removal of duplicates and assessment of titles, 10,912 articles were removed.
A total of 129 articles were reviewed by abstract (and full text, where needed) and assessed
individually against the selection criteria. In total seventy-two publications met the criteria and
were included in the review.
Figure 1: Evidence Review Flow Diagram
Source: Based on PRISMA (Moher et al. 2009)
Supplementary table of data, including a list of seventy-two publications included in the
review, is located here: http://hdl.handle.net/1885/143812.
Characteristics of Studies
In the review there were similar amounts of quantitative (n=34) and qualitative data (n=33),
although few publications reported mixed-method approaches (n=5). The vast majority of
publications came from studies in Canada (n=40) and Australia (n=26), with others from New
Zealand (n=3) and the United States (n=3).
Records after duplicates removed
(n = 11041)
Records excluded
(n = 10912)
Full-text articles assessed for
eligibility (n = 129)
Full-text articles excluded,
with reasons (n = 67)
Manuscripts on culture, wellbeing
health associations (n = 72)
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BOURKE AND WRIGHT ET AL.: EVIDENCE REVIEW OF INDIGENOUS CULTURE FOR HEALTH
Table 3: Characteristics of Studies Included in the Review
All publications
Australian
publications
International
publications
n (%) n (%) n (%)
Study design
Mixed methods 5 (7) 2 (3) 3 (4)
Quantitative 34 (47) 13 (18) 20 (28)
Qualitative 33 (46) 11 (15) 23 (32)
Sample size
n<50 29 (40) 8 (11) 21 (29)
51<n<200
13 (18)
8 (11)
5 (7)
201<n<2000 12 (17) 5 (7) 7 (10)
n>2000
17 (24)
5 (7)
12 (17)
Unknown 2 (3) 1 (1) 1 (1)
Source: Authors 2018
There has been substantial growth in the number of publications over time (see Figure 2),
peaking in 2015 (n = 14). In total, 38 percent of publications (n = 26) were based on studies with
Aboriginal and Torres Strait Islander peoples, with these publications contributing to the growth
overall after 2008. The total number per year of Australian publications has not increased over
time, but there has been a small and consistent annual number of publications since 2008.
Figure 2: Number of Publications on Health and Culture Relationships by Year and Location, 1998-2017
Source: Authors 2018
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Evidence Quality and Main Outcome Reported
In total, 29 percent of publications were found to provide a low quality of evidence (n = 27) and
51 percent were assessed as moderate quality of evidence (n = 38). Only 10 percent were scored
as high quality of evidence (n = 7). Particular factors which contributed to the low scoring of
publications was lack of precision (63%, n = 45) and considerable study limitations (80%, n =
58). The consistency of the evidence reported was unknown in many publications (n = 22) or
inconsistent (n = 12), and around half had suspected reporting bias (49%, n = 35). A majority of
studies included an Indigenous viewpoint (61%, n = 44). Those few publications that scored high
in strength of evidence meet six or more evidence assessment criteria, and these studies all
concentrated on more than one cultural domain (discussed below). Studies that were rated high
used either mixed or quantitative methods.
Table 4: Assessment of Evidence Using the AHRQ Framework and the Main Effect
Evidence assessment Categories Number of studies % of studies
Indigenous viewpoint Yes 28 39
No 44 61
Study limitations Low 14 19
Medium 19 26
High 39 54
Directness
Direct
60
83
Indirect 12 17
Consistency Consistent 38 52
Inconsistent 10 14
Unknown
24
33
Precision Precise 27 37
Imprecise 45 63
Reporting bias
Suspected
35
49
Undetected 37 51
Strength of evidence
Low 28 39
Moderate 37 51
High 7 10
Main effect reported
Positive
61
85
Negative 2 3
Mixed 9 12
Source: Authors 2018
In total, 85 percent (n = 61) of publications reported positive associations between
Indigenous cultures and health. An additional 12 percent (n = 9) of articles reported mixed results
with both positive and non-significant associations. Only 3 percent of publications (n = 2)
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BOURKE AND WRIGHT ET AL.: EVIDENCE REVIEW OF INDIGENOUS CULTURE FOR HEALTH
reported an inverse (negative) association between health measures and some elements of culture
(Morrison et al. 2014; Rotenburg 2016).
A large number of publications analysed social and emotional wellbeing outcomes
associated with greater participation or involvement in culture (58%, n = 42) (Table 4). Almost
all of these studies reported positive effects (n = 40), with the remaining two studies reporting
mixed effects.
Physical health outcomes (e.g., systolic blood pressure, body mass index, cholesterol levels,
diabetes) were reported in sixteen publications. Of these, ten publications reported positive
associations between these outcomes and culture, four reported mixed effects, and two reported
negative associations. For these two articles that reported negative relationships, Rotenburg
(2016) found that those who participated in a traditional activity were more likely to have a
chronic condition, and Morrison et al. (2014) demonstrated that First Nation Canadians living on
a reserve were twice as likely to be hospitalised as First Nation Canadians living off reserves.
Behavioural risk factors (e.g., smoking, nutrition, physical activity, alcohol consumption)
and their associations with culture were reported in twenty publications (Table 5). A small
number of publications (n = 5) reported on more than one main health outcome (e.g., physical
health and social and emotional wellbeing, physical health and risk factors).
Table 5: Main Health Outcome by Effect Reported in the Publications
TOTAL
articles (%)
Number of studies
reporting a
positive
association
Number of studies
reporting a
negative
association
Number of
studies with
reporting mixed
effects
Health outcome
Social and
emotional wellbeing
42 (58) 40 0 2
Physical health 16 (22) 10 2 4
Risk factors 20 (22) 16 0 4
Not defined 1 (1) 1 0
Source: Authors 2018
Additionally, a number of studies that discussed health and culture also reported on
historical events and the ongoing effects of colonisation for Indigenous individuals and
communities. This included evidence of exposure to racism, impacts of the Stolen Generation in
Australia, residential schools or forced removal, segregation, and assimilation policies. Several
studies found a negative relationship between colonial domains and health, whilst others could
not identify an association (Cairney et al. 2017; Chandler et al. 2003; Chandler and Lalonde
2008; Yap and Yu 2016). No studies reported a positive relationship between colonial policies
and health.
Cultural Domains Explored in the Studies
All publications could be linked with one or more defined cultural domains. The domain most
explored in the literature was cultural expression (n = 35) and the least explored domain was self-
determination (n = 18) (Figure 3). In the Australian studies, the two most explored cultural
domains were country (n = 13), and kinship and family (n = 13).
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THE INTERNATIONAL JOURNAL OF HEALTH, WELLNESS, AND SOCIETY
Figure 3: Focus of Publications by Cultural Domain and Location
Source: Authors 2018
There were observable differences when cultural domains were examined by study design.
Firstly, there was a larger proportion of quantitative studies in the cultural domains of language
(68%), cultural expression (57%), and country (53%) (Figure 4). Cultural domains of self-
determination (50%), knowledges and beliefs (55%), and kinship and family (65%) were more
likely to be studied using qualitative methods. While very few studies used mixed-method
approaches, these studies often examined several cultural domains.
Figure 4: Cultural Domains Explored in the Publications by Study Design Type
Source: Authors 2018
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BOURKE AND WRIGHT ET AL.: EVIDENCE REVIEW OF INDIGENOUS CULTURE FOR HEALTH
When Australian studies are analysed separately from other international Indigenous studies,
there is a greater distinction between what domains are studied qualitatively and quantitatively.
Very few quantitative studies in Australia examined self-determination (n = 1), knowledges and
beliefs (n = 1), and family and kinship (n = 1) (see Figure 5), compared to twenty-five
international studies from other Indigenous populations that quantitatively measured self-
determination (n = 8), knowledges and beliefs (n = 9), and family and kinship (n = 8).
Figure 5: Cultural Domains Explored by Location (Indigenous Studies and Australian Studies) and Study Design Type
Source: Authors 2018
Discussion
The twenty years of evidence reviewed presents an emerging and critical body of work
addressing the demands of both Indigenous communities and policy-makers. The evidence from
this review provides support for the positive associations between health, wellbeing, and the
cultures of Indigenous peoples. Many of the studies examined encompassed multiple cultural
domains. Further, the evidence was situated across a variety of health and wellbeing outcomes,
including social and emotional wellbeing (e.g., Allen et al. 2017; Bals et al. 2011; Biddle and
Crawford 2017; Biddle and Swee 2012; Richmond and Ross 2008; Dockery 2009, 2011),
physical health (e.g., Campbell et al. 2011; Dyck et al. 2015; Morrison et al. 2014; Oster et al.
2014; Burgess et al. 2008), and behavioural risk factors associated with health (Johnston and
Thomas 2008; Wham et al. 2015). There was a predominance of studies that researched social
and emotional wellbeing, and the evidence from all of these studies demonstrated a positive
relationship with Indigenous cultures and culturally-based interventions. This indicates a need for
more studies to examine physical health and behavioural risk factors. Nevertheless, the fact that
the evidence sits across a diversity of health and wellbeing outcomes is encouraging for
comprehensive health and wellbeing programs and policies, as it supports Indigenous definitions
of the interconnected and holistic nature of health.
Many of the studies were cross-sectional and were localised to a specific community or
region. The focus on local and regional studies may be a result of the distinctiveness of different
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THE INTERNATIONAL JOURNAL OF HEALTH, WELLNESS, AND SOCIETY
Indigenous cultures within a country, and internationally. It is also likely that resourcing issues in
undertaking large-scale studies restricted the ability of researchers to study larger groups of
people. Further, many of the qualitative studies were informing larger pieces of ongoing research
work, discussing concepts, and building conceptual frameworks to be used in future research, or
policy and program work. This presents difficulties in generalising findings to populations, and
in understanding causality and potential pathways to better health. The few national studies
reviewed here mostly relied on secondary source data from census or national government
surveys (Dockery 2009, 2011; Biddle and Crawford 2017; Biddle and Swee 2012). Reliance on
these routine data collections can place restrictions on the types of questions asked and variables
measured. Further, it means that conceptual framing and Indigenous viewpoints are largely
missing. These restrictions on study design also lead to descriptive results or cross-sectional
associations, as few studies were able to reliably report on causal relationships. There were also
very few longitudinal cohort studies. This presents an important avenue for future research.
The strength of available evidence examining the relationship between cultural factors and
health for Indigenous peoples is moderate to low. Reporting bias was common due to the
predominance of observational studies. In applying the AHRQ framework, we also identified
that, overall, many studies lacked precision, had large numbers of limitations and/or were
inconsistent. These characteristics may be due to the newness of the study material, diversity of
health and cultural domains included in the review, and the dominance of small-scale studies. It
is also a reflection of the difficulties faced by studies which seek to link complex, evolving, and
dynamic societal phenomenon like culture and wellbeing. These challenges were apparent when
the cultural domains were analysed by study design in this review. Our results demonstrated that
studies of language (e.g., do you speak…) and cultural expression (e.g., have you attended or
participated...) led themselves to be assessed through quantitative studies, whereas domains such
as kinship and family, and knowledges and beliefs are inherently more difficult to define, and
hence, more likely to be described and detailed in qualitative studies.
The complexity involved in measuring and defining cultural domains underscores the ability
to accurately assess the reliability and validity of this work. We used a framework (Berkman et
al. 2015) that allowed a variety of study designs to be included in the review. However, the
framework required some adaptation, and it may inadvertently favour quantitative studies over
other studies, as the characteristics it assessed aligned more with these types of studies (e.g.,
precision, bias, consistency). It is likely then that different interpretations or assessments of these
studies may be made. Even within the reviewing team, much discussion arose on categorisation,
measurements and what constituted evidence on the linkage between health and culture. Further
limitations of our review included using databases to locate peer reviewed publications, which
may not have captured all the applicable grey literature or evidence in books. We cannot rule out
that these sources might have influenced our results.
In saying this, the review team is aware that others may dismiss the findings of this review
based on theoretical rather than empirical grounds, as the ability to effectively define and
concisely measure concepts of culture is an area which is hotly contested (Merlan 2000; Rowse
2010, 2009). These arguments suggest that categorising a social phenomenon is inappropriate, as
it fails to capture diversity and heterogeneity among Indigenous peoples and communities. This
includes the everyday lived experiences of culture as it arises in a place and time (Macintyre,
Ellaway, and Cummins 2002), which may be more important than collective expression, events,
or specific elements (Rowse 2010).
Despite imperfections in measurement, the research team believes that this review is a
valuable contribution to the evidence base, and supports and works toward validating the
knowledge of Indigenous elders. Given that the evidence review has shown that the majority of
the literature identifies a positive relationship between health and Indigenous cultures, future
efforts to design valid measures of cultural domains, health; and wellbeing would be valuable.
Additionally, the role of mixed methods in capturing valid measures of social concepts, lived
22

BOURKE AND WRIGHT ET AL.: EVIDENCE REVIEW OF INDIGENOUS CULTURE FOR HEALTH
experiences, and cultural expression of Indigenous peoples is likely to be an important part of
future research. This would then lend greater confidence and credibility to “what is measured.”
The literature reviewed represents an emerging body of published evidence. The peak of
publication in more recent years highlights a growing awareness by researchers to better examine
“the determinants of the determinants of health” (Marmot 2011; The Lowitja Institute 2016). It is
also likely to represent the effort of health researchers and public health institutions to conduct
and fund projects that may have been considered to be outside prevailing health expertise,
methods and models (O’Donoghue 1999). It may also reflect recent developments in ethical
standards for health research with Indigenous peoples, in which researchers seek to do research
that is reciprocal, benefits communities, and partners with communities to examine their research
needs and interests (Humphery 2001; Dunbar and Scrimgeour 2006). The onset of Australian
studies published from 2008 is interesting, as it coincides with the 2008 Apology to Australia’s
Indigenous Peoples by the then Prime Minister Kevin Rudd (Rudd 2008). The increase in
publications is likely also to be driven by a heightened awareness that biomedical models and
interventions are failing to improve outcomes for Indigenous peoples on a global scale (Anderson
et al. 2016). Solutions for improving overall health and wellbeing may well arise from within
Indigenous communities and their knowledges, cultures, lived experiences and customs (The
Lowitja Institute 2016).
The growing attention on negative outcomes associated with colonisation, decolonisation,
assimilation, and forced removal of people from place may be driving a research agenda that
seeks to re-imagine and better identify the strengths of Indigenous peoples and their cultures
(Priest, Paradies, Stewart, et al. 2011; Priest, Paradies, Gunthorpe, et al. 2011; Anderson and
Kowal 2012; Ferrazzi and Krupa 2016; Lewis and Allen 2017; Waterworth et al. 2015). The
negative outcomes associated with colonial histories have become politicised in such a way that
alternative strength-based solutions are becoming more influential. These approaches suggest
that answers ought to be found in strengthening the undermined, revitalising what was lost, and
enabling communities to address their own challenges. This is supported by ongoing work,
particularly from psychology disciplines, including the work of Chandler, Lalonde and their
research team (Chandler and Lalonde 1998, 2008; Chandler et al. 2003; Chandler and Proulx
2006) and others (MacDonald et al. 2015; Skerrett et al. 2017). These studies have highlighted
that wellbeing outcomes, reduced suicides, and other mental health outcomes are associated with
improved community autonomy and decision-making.
Overall, the most important test of this evidence is whether it can capture and build societal
change, and thus impact on health and development outcomes for Indigenous peoples. This will
mean that research efforts are translatable to community action and are able to influence both
public health policy and practice, including broader social and community development
programs. Influencing these policy and practice settings requires robust evidence, defined not
only by the study designs and methodological approaches, but by the interpretability and use in
communities and national policy agendas. As such, a critical analysis of political and research
paradigms is needed to change the state of health and wellbeing of Indigenous peoples.
Acknowledgement
This review was funded and supported by the Lowitja Institute, (Grant No 16-SDH-05). RL is
supported by an NHMRC Research Fellowship (Grant No 1088366). AW is supported by an
Australian Government Research Training Scholarship. We also acknowledge all the Mayi
Kuwayu Study team, investigators, and partners who are contributing to the development of the
study.
Conflict of interest: The authors have no conflicts of interest to declare.
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ABOUT THE AUTHORS
Sarah Bourke: DPhil in Anthropology Candidate, School of Anthropology and Museum
Ethnography, University of Oxford, Oxford, United Kingdom
Alyson Wright: PhD Candidate, National Centre for Epidemiology and Population Health,
Research School of Population Health, Australian National University, Canberra, Australia
Dr. Jill Guthrie: Senior Research Fellow, National Centre for Epidemiology and Population
Health, Research School of Population Health, Australian National University, Canberra,
Australia
Lachlan Russell: Research Manager, National Centre for Epidemiology and Population Health,
Research School of Population Health, Australian National University, Canberra, Australia
Terry Dunbar: Associate Professor, Yaitya Purruna Indigenous Health Unit, Faculty of Health
and Medical Sciences, University of Adelaide, Adelaide, Australia
Raymond Lovett: Associate Professor, National Centre for Epidemiology and Population Health,
Research School of Population Health, Australian National University, Canberra, Australia
27

The International Journal of Health, Wellness
and Society offers an interdisciplinary forum for the
discussion of issues at the intersection of human
physiology and the social life conditions. It is a focal
point for scholarly and practice-based discussion in
a time of growing public and research awareness of
the relations between health and social wellbeing.
The concept of “health and wellness” impacts all
members of society, whether at a personal level in the
positive senses of life-satisfaction and exhilaration,
or problematically, through the cost and availability of
remedial health care. Contributions to the journal range
from broad scientific, sociological, philosophical, and
policy explorations to detailed studies of particular
physiological and social dynamics.
As well as article of a traditional, scholarly type, this
journal invites case studies that take the form of
presentations of practice—including documentation of
socially engaged practices and exegeses analyzing the
effects of those practices.
The International Journal of Health, Wellness and
Society is a peer-reviewed, scholarly journal.
ISSN 2156-8 96 0