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Measuring the health and wellbeing impacts of cultural camps
among Aboriginal adults: preliminary evidence from the
Gaawaadhi Gadudha Research Collaborative
Brooke Brady,
a
,
b
,
c
,
∗
Anthony B. Zwi,
f
Jonathan Kingsley,
g
Michelle O’Leary,
d
,
e
Nina Serova,
d
Stephanie M. Topp,
h
,
f
Brett J. Biles,
e
,
i
Ted Fields,
d
,
e
Warren Foster,
d
,
e
and Aryati Yashadhana
d
,
e
,
f
a
School of Psychology, University of New South Wales, Sydney, NSW, Australia
b
Neuroscience Research Australia, Sydney, NSW, Australia
c
UNSW Ageing Futures Institute, University of New South Wales, Sydney, NSW, Australia
d
Centre for Primary Health Care & Equity, University of New South Wales, Sydney, NSW, Australia
e
School of Population Health, University of New South Wales, Sydney, NSW, Australia
f
School of Social Sciences, University of New South Wales, Sydney, NSW, Australia
g
School of Health Sciences, Swinburne University of Technology, Melbourne, Victoria, Australia
h
College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia
i
Deputy Vice-Chancellor Indigenous Division, University of New South Wales, Sydney, NSW, Australia
Summary
Background Aboriginal and Torres Strait Islander peoples’have sustained their cultural practices for over 60,000 years
which fundamentally impacts their health and wellbeing. Recent literature emphasizes cultural connection as a
contributor to good public health, yet the mechanisms through which cultural engagement promotes health and
wellbeing remain underexplored. This study investigates the health and wellbeing outcomes associated with
Aboriginal peoples’participation in cultural camps in New South Wales (Australia), focusing on the role of cultural
determinants of health.
Methods This cohort study, part of the larger Gaawaadhi Gadudha Research Collaborative, examines the impact of
camp attendance on health indicators among Aboriginal adults. Participants (N = 43) completed surveys assessing
individual cultural health, access to cultural resources, resilience, and health-related quality of life pre and post camp.
Paired-samples t-tests and Wilcoxon related samples signed-rank tests were employed to analyze changes.
Findings Participants reported high engagement in cultural activities and positive experiences at camps. Post-camp
responses indicated significant improvements in cultural health, including increased pride in cultural identity,
knowledge of traditions, and connections to Country and community. However, measures of resilience and
health-related quality of life showed no reliable changes.
Interpretation The findings suggest that camps play a crucial role in enhancing cultural health among Aboriginal
peoples, reinforcing the importance of knowledge of cultural determinants of health. This study underscores the need
for further research to explore the long-term impacts of cultural engagement on health and wellbeing and highlights
the potential of cultural camps as a model for health promotion initiatives within Aboriginal communities.
Funding This study was funded by the Australian Government’s Medical Research Future Fund (MRF2009522).
Copyright © 2024 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Keywords: Indigenous; Cultural determinants of health; Land; Resilience; Healing
Introduction
Continuity in Aboriginal and Torres Strait Islander
(herein Aboriginal) cultures has been present for over
60,000 years; and is ever evolving.
1–3
Aboriginal models,
frameworks and concepts of health are deeply connected
to culture, Country (i.e., land), kin, history, protocols,
language, identity, and community.
3
Although an
emergent body of literature highlights cultural
*Corresponding author. School of Psychology, University of New South Wales, Sydney 2052, Australia.
E-mail address: b.brady@unsw.edu.au (B. Brady).
The Lancet Regional
Health - Western Pacific
2024;52: 101200
Published Online 10
November 2024
https://doi.org/10.
1016/j.lanwpc.2024.
101200
www.thelancet.com Vol 52 November, 2024 1
Articles
connection as a public health preventative measure in
Aboriginal populations,
3–5
there is a lack of evidence
identifying how and what mechanisms lead to these
health and wellbeing benefits.
4,6–8
The concept of the
cultural determinants of health allows us to better un-
derstand this relationship. Cultural determinants of
health are defined by the National Institute of Aboriginal
and Torres Strait Islander Health Research (Lowitja
Institute) as: “promot[ing] a strength-based perspective,
acknowledging that stronger connections to culture and
country build stronger individual and collective identities, a
sense of self-esteem, [and] resilience”.
9
In this paper, we explore the relationships between
Aboriginal peoples’engagement with cultural camps
(herein camps) on Country, and several indicators of
health and wellbeing, including individual connection to
culture, access to cultural resources, resilience, and
health-related quality of life. Culture and Country are
intimately intertwined for Aboriginal peoples’health
and wellbeing.
10–12
Specific to Australia, this is because
connection to Country is unbroken for Aboriginal peo-
ples and refers to a “deep, intimate, holistic, complex,
localized, and reciprocal relationship which includes ele-
ments of the land, sea, waterways, sky, stars, and living and
nonliving entities …Country is more than something you
just see as a physical entity—it is a living system tied to
language, identity, and customs; it is not static or frozen in
time, incorporating the social, spiritual, and cultural link-
ages of Aboriginal and Torres Strait Islander peoples”.
3
Country teaches, speaks, and connects communities in
a reciprocal relationship with animals, plants, rocks,
water and sea through time and space and is passed on
through actions, activities and protocols like songlines,
language, fire, food and medicine, seasonal calendars
and ceremony.
3,4,13
A separate but related body of work
has also explored cultural connection and connection to
Country in the context of Aboriginal constructs of
resilience,
14–16
refining conceptualisations of the role of
culture and Country in promoting health and resilience
and developing tools to evaluate those links. Very
limited research has been conducted examining the
effectiveness of practices and programs designed to
strengthen these links. In one notable example Dobia
et al.
17
measured the effects of Aboriginal Girls’Circles
on participants’resilience, connectedness, self-concept
and cultural identity, evaluating the relative effective-
ness of various components of the program and
reporting positive impacts. However, there remain sig-
nificant knowledge gaps in relation to the measurable
health impacts of practices and programs designed to
promote connectedness to culture and Country, such as
camps.
The cultural camps
This study centres on three camps, held, respectively, on
Yuwaalaraay, Gamilaraay, and Yuin-Djirringanj Country
in New South Wales in 2022. The camps involve expe-
riences with cultural lore, traditional languages, and
Research in context
Evidence before this study
Prior to this study, the evidence for cultural connection as a
contributor to health and wellbeing was largely conceptual or
qualitative.
Added value of this study
The added value of this study lies in its empirical exploration
of the health and wellbeing impacts of attending cultural
camps among Aboriginal peoples within the Australian
context. This study employs a comprehensive evaluation
protocol to quantitatively assess changes in individual cultural
health, access to cultural resources, resilience, and health-
related quality of life pre- and post-camp attendance.
Furthermore, the study has value for policy and practice,
offering empirical support for the role of cultural camps as
effective public health programs that can enhance cultural
connection, sense of identity, and wellbeing. This evidence is
crucial for informing health policies and practices that
prioritize cultural determinants and strength-based
approaches.
Implications of all the available evidence
Overall, the study findings combined with existing evidence
highlight the critical role of cultural connection as a
determinant of health and wellbeing among Aboriginal
peoples. The implications of this evidence for policy and
practice include, firstly, recognition of the need to integrate
cultural determinants in public health strategies and health
programming, highlighting the importance of culture,
Country, and community in promoting health and wellbeing.
This includes the development and support of culturally
centred programs, such as cultural camps, that facilitate
engagement with culture and Country. Secondly these
research insights aim to increase policy support and
resourcing for Aboriginal-led initiatives that strengthen
cultural connection. There are also implications for future
research including: i) investing in longitudinal research to
assess the long-term impacts and sustainability of health
benefits derived from cultural engagement and participation
in cultural camps; and ii) investigation of the mechanisms
through which cultural connection influences health
outcomes. This might include exploration of whether specific
aspects of cultural engagement are most beneficial and
determining if and how they interact with other determinants
of health.
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2 www.thelancet.com Vol 52 November, 2024
connection to and understanding of cultural landscapes
(including learning to identify traditional foods and
medicines). The camps are regularly organised by cul-
tural knowledge holders —who are Aboriginal custo-
dians of both Country and immaterial aspects of culture,
such as language, stories and law —outside of this
research. The camps form part of the knowledge
holders’work that supports the continuation of culture.
They welcome Aboriginal people from all nation groups.
Cultural knowledge holders invite camp participants
through their networks, via advertisements and word-of-
mouth, in person and on social media. They welcome
Aboriginal and Torres Strait Islander people from all
nation groups. Families are invited, including non-
Aboriginal family members. The camps, which are be-
tween three and five days in length, are held on Country,
in proximity to sites that are sacred to the relevant lan-
guage group. For example, Dharriwaa, where the
Yuwaalaraay camp is held, is a traditional meeting place,
which holds sites connected to significant ancestral
stories. Women, men, and families are invited to camp
separately (participants can choose their camp) and all
meet for mealtimes and for cultural involvement,
including gender specific activities. By facilitating
connection to cultural landscapes (e.g., physical sites
minimally impacted by colonisation, including natural
and sacred sites protected from urbanisation or devel-
opment)
3,18
and transgenerational and intercultural
knowledge exchange, the camps aim to encourage cul-
tural and kinship connection, decolonization, and heal-
ing for participants. Fig. 1 shows images from the
Dhariwaa (Yuwaalaraay) and Yuin (Yuin-Djirringanj)
camps.
The current study aims to honour Aboriginal
models, frameworks, and concepts of health by
providing initial evidence for the health and wellbeing
impacts of attending cultural camps. We do so through
the lens of a strength-based approach which seeks: “… to
move away from the traditional problem-based paradigm
and offer a different language and set of solutions”that
centre Aboriginal cultures, and ways of being, knowing,
and doing.
3
Specifically, we aim to explore pre- and post-
camp quantitative indicators of individual cultural
health, including access to cultural resources, individual
and relational resilience, and health-related quality of
life of Aboriginal adults who attended camps. This study
extends previous international work
19
by exploring the
health impacts of attending cultural camps using a more
extensive evaluation protocol than previously under-
taken in the Australian context.
Methods
Study design
This cohort study is part of the Gaawaadhi Gadudha
Research Collaborative. More detailed information
regarding the broader study conceptualisation, gover-
nance structure and methodology can be found in the
project’s study protocol paper.
8
Nonetheless, in the
following paragraphs we provide a brief overview of
each of these factors as relevant to the aims of the
current study. Companion papers in the series explore:
the need to rethink the ‘health gap’between Aboriginal
and non-Aboriginal populations as instead a need to
strengthen cultural connection
20
;theconceptofcul-
tural health through a narrative review of the litera-
ture
21
; and how health and wellbeing are
phenomenologically connected to cultural practices,
foods, medicines, languages, and Country using qual-
itative data collected at cultural camps.
22
The current
paper reports specifically on pre-to post-camp quanti-
tative data exploring the impact of camp attendance on
a range of health and wellbeing indicators. Ethics
approval was obtained from the Aboriginal Health and
Medical Research Council (#1851/21).
Cultural governance
The Gaawadhi Gadudha Research Collaborative (herein
Research Collaborative), which this study is a part of,
Fig. 1: Images taken at Dhariwaa camp (left) and Yuin camp (right).
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was conceptualised in close partnership with traditional
cultural knowledge holders (TF, MO, WF) from
Yuwaalaraay, Gamilaraay, and Yuin Aboriginal Nations
of New South Wales (NSW) Australia. More information
on the Collaborative can be found in the qualitative
article in this collection (Yashadhana et al., 2024). The
Gaawaadhi Gadudha Cultural Governance Group
(herein Cultural Governance Group), composed of these
knowledge holders, led decision-making in their
respective locations in relation to research governance,
design, implementation, data collection, data analysis,
and dissemination. As described in the study protocol,
8
the cultural health surveys reported in the present study
were developed with oversight from the Cultural
Governance Group, to ensure all content was culturally
appropriate and meaningful to the study aims.
Participants
Aboriginal adults aged 18 years or older were invited to
participate in this research by completing at least one
cultural health survey. A total of 320 adults consented to
and completed at least part of the pre-camp survey. Of
those, 166 indicated that they were intending to partic-
ipate in an upcoming camp, and 154 indicated that they
were not. We refer to these samples as the camp cohort
and the comparative cohort, respectively. The camp
cohort were invited to participate via email after they
had registered to attend a camp, and some were invited
to participate at the beginning of the camp before ac-
tivities commenced. The comparative cohort was
sampled from the same regions in which the camps
took place. This study does not report on data from the
comparative cohort. A total of 65 participants consented
to and completed at least part of the post-camp survey.
Some of those respondents had not completed a pre-
camp survey. As the present study is interested in pre-
to post-camp differences, we report only data from
those who i) participated in a camp and ii) completed
both the pre- and post-camp surveys (N = 43). This
sample size is sufficiently powered to detect small-to-
moderate effect sizes in paired-samples tests, with
alpha (two-tailed) = 0.05 and power of 0.80.
23
More de-
tails of sample characteristics are reported in the results
section.
Procedure
Community-based researchers were available to all par-
ticipants to explain the study thoroughly and privately
prior to participants providing informed consent. Those
who consented had the choice of completing each sur-
vey on their own, or with assistance from a research
team member. The survey was designed using Qual-
trics
24
and data were collected electronically using a
personal device or provided tablet. Data collected
included personal characteristics, cultural identities and
responsibilities, camp experiences, individual cultural
health, access to cultural resources, resilience, and
health-related quality of life. The pre-camp survey took
approximately 40 min to complete and was adminis-
tered within two weeks of attending a cultural camp.
The post-camp survey took approximately 30 min to
complete and was administered during the final hours
of each cultural camp. Aside from eligibility questions
(age, Aboriginality), all survey questions were optional,
and respondents could skip any item they did not wish
to answer. The pre- and post-camp surveys are included
in the Supplementary Materials. Respondents received a
$40 AUD grocery voucher for their time after
completing each survey.
Outcomes
Personal characteristics
Participants were asked to report their age in years,
gender identity (“male”,“female”,“non-binary or third
gender”,“I use another term”(text entry), “prefer not to
say”), main source of income (“full time employment”,
“part time employment”,“casual employment”,“Cen-
trelink (social welfare) payments”,“I don’t have an in-
come”), housing situation (“living in own home”,“living
in rented home”,“living in affordable housing”,“living
in public housing”,“living in Aboriginal housing”,
“living temporarily with friends or family”,“houseless”)
whether they were currently living on their own Country
(“yes”,“no”), and the preferred term they used when
describing their cultural identity. Participants could
select from a range of identities or type in their
preferred identity using open text. The survey also
collected some additional personal and cultural charac-
teristics not reported here.
Overall camp experience and activities
Participants were asked to rate their overall experience
at camp using a sliding scale from 1 (extremely negative)
to 100 (extremely positive). They were asked if they
would be interested in attending the next camp gath-
ering, with response options including “yes”,“no”or
“maybe”. They were also asked to indicate how much
time they felt they spent on a range of activities at camp,
using a Likert-type scale from 1 (“none”)to5(“a great
deal”).
Individual and collective access to culture, cultural knowledge,
and resources (cultural health)
Repeated measures. This study included repeated
measures of cultural health that were completed both
pre- and post-camp. Individual connection to culture
was measured using a combination of selected items
from the Mayi Kuwayu Survey,
25
and the Cultural
Connectedness Scale.
26
Items were selected based on
their relevance to the study aims
8
and were discussed at
length with the Cultural Governance Group. Some
items were modified to suit the local context. For
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example, instead of using the term ‘Aboriginal’, the
participant’s self-identified cultural group was piped
into questions. Items around individual and collective
access to culture were developed by the Gaawaadhi
Gadudha Research Collaborative and Cultural Gover-
nance Group and drew on the experience and previous
work on cultural heritage previously undertaken by one
of the knowledge holders (TF).
Stand-alone measures. As cultural health is of central
interest in this study, we also included a series of stand-
alone items which were designed to detect meaningful
changes in aspects of cultural health related to attending
the camps which may not be detectable using the
measurement approach above. For example, we antici-
pated that at least a portion of the sample would rate at
the highest ends of Likert-type scales on cultural health
indicators prior to the camps, leaving no capacity for
measures to reflect potential positive change following
the camps. An example stand-alone item is “How did
your knowledge of history, traditions and customs
change as a result of attending the Camp?. The 5-point
response scale (“decreased a lot”,“decreased a little”,
“no change”,“increased a little”,“increased a lot”) was
designed to allow for both positive and negative changes
in cultural health indicators.
Resilience
This study included two measures of resilience: an 18-
item Adaptation of the Aboriginal Resilience and Re-
covery Questionnaire (ARRQ)
14,27
and the 10-item
Connor-Davidson Resilience Scale (CD-RISC).
28
The
original ARRQ was developed through a process of
consultation and collaboration with Aboriginal adults
and was specifically designed to be culturally appro-
priate and sensitive to the experiences of Aboriginal
people in Australia. Permission was granted from the
author of the ARRQ
14,27
to create an adapted version of
selected survey items to be used in the study. Our
adaptation (developed by AY and BB with iterative
feedback from the Cultural Governance Group) consists
of 18 items grouped into two subscales: sources of
personal strength (8 items) and sources of relational-
community-cultural strength (10 items). Among the
current sample, responses to the pre-camp survey were
used to calculate scale reliability which was found to be
very good for both the personal strengths (Cronbach’s
α= 0.875) and the relational-community-cultural
strength subscales (Cronbach’sα= 0.873). Items
within each subscale, item scores and item-total statis-
tics are presented in Supplementary Table S1.
The 10-item CD-RISC
28
is a widely used measure of
individual resilience. The scale consists of 10 items,
each rated on a 5-point Likert-type scale ranging from 1
(not true at all) to 5 (true nearly all the time). Example
items include “I am able to adapt when changes occur”
and “I tend to bounce back after illness, injury, or other
hardships.”Item scores are summed to create a total
resilience score ranging from 10 to 50, with higher
scores indicating greater resilience. This measure has
been used in previous research among Aboriginal
adults
14
and demonstrated good reliability in the current
sample based on pre-camp survey responses (Cron-
bach’sα= 0.883).
Health-related quality of life and self-rated health
The EQ-5D-5L
29
is a self-report measure of health-
related quality of life. The measure includes a visual
analogue scale, which allows individuals to rate their
overall level of health-related quality of life on a scale
from0to100,withhigherscoresindicatingbetter
overall health-related quality of life. It also assesses an
individual’s health status across five dimensions of
health, including: mobility, self-care, usual activities,
pain/discomfort, and anxiety/depression. Each
dimensionismeasuredonafive-point scale, ranging
from 1 “no problems”to 5 “extreme problems.”Higher
scores indicate poorer health status. The EQ-5D-5L has
been shown to be a suitable measure of health-related
quality of life among a large sample of Aboriginal
people.
30
Statistical analysis
Descriptive statistics were used to summarize the
sample characteristics and stand-alone items exploring
the impact of attending camp on cultural health.
Continuous variables (e.g., age) were described using
means and standard deviations, while ordinal or cate-
gorical variables (e.g., gender, housing status, camp
impacts) were described using frequencies and per-
centages. As outlined in the study protocol,
8
we aimed
to conduct regression analyses to explore pre-to post-
camp differences in health indicators after controlling
for possible covariates such as age or gender. However,
significant drop-off in the completion rates from the
pre-to post-camp surveys resulted in a smaller than
anticipated sample size, precluding the capacity to
include covariates in statistical models (discussed later
in this paper). As such, we used paired-samples t-tests
(for continuous measures) and Wilcoxon related sam-
ples signed-rank tests (for ordinal measures) to explore
pre-to post-camp differences in cultural health in-
dicators, resilience, and health-related quality of life.
Pairwise deletion was used to handle missing data,
because complete pre-post data was important for
many of the planned analyses. All statistical analyses
were computed using SPSS Version 26.
31
Interpreta-
tion of results was guided by the Cultural Governance
Group.
Role of the funding source
The funder of the study had no role in study design, data
collection, data analysis, data interpretation, or writing
of the report.
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Results
This paper reports on data from 43 Aboriginal adults (29
females, 14 males; mean age = 44.3 years, age range
19–74 years) who completed both the pre- and post-
camp surveys. Before attending the camp, most at-
tendees spent at least a little time on a range of cultural
activities, see Supplementary Table S2. Sample charac-
teristics are described in Table 1.
Attendees’perceptions of the amount of time spent
on a range of cultural activities at camp are summarised
in Table 2, which indicated engagement across the full
range of activities surveyed.
Overall, attendees rated their experience at camp as
extremely positive, with an average rating of 93.85/100
(SD = 8.27, range 66–100). Responses were clustered at
the highest end of the reporting scale, with 46.2% of
people rating their experience 100/100 and 82.7%
providing a rating of 90/100 or higher. 95.3% of people
said they would like to attend the next cultural camp
offered, and the remaining 4.7% said ‘Maybe’.
Wilcoxon related samples signed-rank tests were
used to compare ratings of specific cultural health in-
dicators from pre-to post-camp. Table 3 shows item
response frequencies and tests of pre-to post-camp
differences. We did not detect any statistically signifi-
cant differences in average responses to cultural health
items across time, with mean scores on the high end of
the response scale at each timepoint.
However, stand-alone post-camp questions revealed
strong positive impacts of attending camp on all cul-
tural health indicators we surveyed. As shown in Fig. 2,
83.7% of people experienced an increase in their own
sense of pride in their cultural identity, and 69.8% an
increase in their perceived importance of being rec-
ognised as Aboriginal. In terms of cultural knowledge,
93% of people said they increased their knowledge of
history, traditions, and customs, 87.5% increased their
knowledge of physical sites of spiritual or cultural
significance, 68.3% increased knowledge of traditional
foods, 70.7% increased knowledge of traditional med-
icines, 77.5% increased knowledge and access to cul-
tural resources, and 85% reported an increase in
knowledge of important cultural stories. When asked
about the impact of camp attendance on perceived
connections, 90% reported increased connection to
other people, 72.1% reported increased connection to
their own Mob or Nation, 86% reported increased
connection to Ancestors, and 85% reported an
increased connection to Country. 85.4% of people re-
ported that they heard or learned new Aboriginal words
or language at camp, and 68.3% reported that they
shared words or language they knew with others.
Remarkably, 97.5% of people indicated that they
experienced a sense of healing as a direct result of
attending the camp.
Paired-samples t-tests were used to compare scores
on the CD-RISC and ARRQ before and after attending a
cultural camp. The was no difference in the average CD-
RISC score before (M= 27.85, SD = 6.15) and after
camp (M= 28.85, SD = 7.36), t(38) = −1.05, 95% CI
[−2.99, 0.99], p= 0.316, Cohen’sd
av
= 0.15, 95%CI
[−0.12, 0.42].
Adapted ARRQ total scores were not significantly
different pre- (M= 56.59, SD = 9.40) and post-camp
(M= 58.85, SD = 7.99), t(38) = −1.79, 95% CI [−4.80,
0.29], p= 0.081, Cohen’sd
av
= 0.26, 95%CI [−0.01, 0.54].
Neither were ratings on the Sources of Personal
Strength subscale pre-camp (M= 25.54, SD = 4.48)
compared to post-camp (M= 26.23, SD = 3.77),
t(38) = −1.22, 95% CI [−1.84, 0.46], p= 0.23, Cohen’s
d
av
= 0.17 95%CI [−0.09, 0.43].
However, we found evidence of a marginally signif-
icant increase in ratings on the Sources of Relational-
Community-Cultural Strength subscale following camp
attendance, t(38) = −2.03, 95% CI [−3.12, −0.01],
p= 0.049. The average pre-camp score was M= 31.05
(SD = 5.67), and the average post-camp score was
M= 32.62 (SD = 5.03). The effect size for the difference
appeared to be small, Cohen’sd
av
= 0.29, 95%CI
[.02, 0.53]. The wide confidence interval suggests that
we cannot rule out that this effect is either very marginal
Variable Response n%
Preferred description of own cultural identity Aboriginal 13 30.2
Bigambul and Gomeroi 2 4.6
Birrbay and Dhanggati 1 2.3
First Nations 4 9.3
Gamilaraay 15 34.9
Indigenous 1 2.3
Kooma 1 2.3
Marra 1 2.3
Yuin 3 7
Yuwaalaraay 1 2.3
Yuwaalaraay and Gamilaraay 1 2.3
Camp attended Dharriwaa (Yuwaalaraay Country) 22 51.2
Gomeroi (Gamilaraay Country) 9 20.9
Yuin (Yuin-Djirringanj Country) 12 27.9
Currently living on own Country Yes 20 46.5
No 23 53.5
Main source of income Full time employment 15 34.9
Part time employment 8 18.6
Casual employment 3 7
Centrelink payments 16 37.2
I don’t have an income 1 2.3
Housing situation Living in a home I own 12 27.9
Living in a home I rent privately or
through a real estate
17 39.5
Living in affordable housing 2 4.7
Living in public housing 2 4.7
Living in Aboriginal housing 7 16.3
Living temporarily with family or friends 3 7
Table 1: Self-reported characteristics of cultural camp attendees (N= 43).
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(at the low end of the confidence interval) or moderate
in strength (at the high end of the confidence interval).
A paired-samples t-test was used to compare average
overall subjective health ratings pre- and post-camp.
There was no statistical difference between pre-camp
(M= 72.18, SD = 15.67) and post-camp health ratings
(M= 75.13, SD = 17.24), t(39) = −1.00, 95% CI [−8.92,
3.02], p= 0.324, Cohen’sd
av
= 0.18, 95%CI [−0.16, 0.53].
Wilcoxon matched-pair signed-rank tests were used to
compare subjective ratings of specific aspects of health-
related quality of life, including mobility, self-care, usual
activities, pain, and anxiety/depression symptoms. As
shown in Table 4, there were no significant differences
in specific health-related quality of life ratings before
and after the cultural camps, with most respondents
indicating little to no difficulty in each domain.
This preliminary study was insufficiently powered to
explore the impact of camp attendance on outcomes
separately for men and women. However, following
guidance from our Cultural Governance Group and to
promote transparency, we provide descriptive data
separately for men and women in the Supplementary
materials (see Supplementary Tables S3–S10).
Supplementary Table S11 displays exploratory bivariate
associations between primary study outcomes measured
both pre- and post-camp and three potential covariates
of interest: age, gender (men, women), and living on
own Country status (yes, no). These covariates were not
sufficiently related to study outcomes to contribute
meaningfully to exploratory regression analyses.
Sensitivity analysis
We are aware that pairwise deletion–used in this study
to account for missing data–may yield biased results.
Therefore, we conducted sensitivity analysis by using
multiple imputations for missing parametric data and
re-running analyses to examine consistency of results.
Overall, 47.51% of variables, 18.6% of cases and 3.32%
of values had missing data. The highest percentage of
missing data (14%) was observed for questions pre-
sented at the end of the post-camp survey. The pattern
of missing values suggested that the values was missing
Thinking about your time spent at camp, how much time did you spend: Response, n(%)
None A little bit A fair bit A lot A great deal
With someone who has cultural knowledge (e.g., Elder or knowledge holder) 0 (0%) 4 (9.5%) 14 (32.6%) 9 (21.4%) 15 (35.7%)
Learning and using knowledge from Aboriginal law/lore 1 (2.4%) 10 (24.4%) 9 (22%) 10 (24.4%) 11 (26.8%)
Getting or eating bush tucker (traditional foods and fishing) 6 (14.3%) 16 (38.1%) 8 (19%) 6 (14.3%) 6 (14.3%)
Learning culture, kinship, and respect 0 (0%) 4 (9.3%) 11 (26.2%) 14 (33.3%) 13 (31%)
Making art, music, paintings 1 (2.4%) 10 (23.8%) 15 (35.7%) 9 (21.4%) 7 (16.7%)
Passing on cultural knowledge 2 (4.9%) 12 (29.3%) 16 (39%) 4 (9.8%) 7 (17.1%)
Contributing to the camp (e.g., by helping, sharing, healing) 0 (0%) 8 (19%) 12 (28.6%) 8 (19%) 14 (33.3%)
Receiving Aboriginal healing methods (traditional healers, bush medicines) 7 (16.7%) 17 (40.5%) 9 (21.4%) 4 (9.5%) 5 (11.9%)
Table 2: Amount of time spent at camp on specific cultural activities.
Item Pre-camp Post-camp Related-Samples Wilcoxon
Signed Rank Test
nNot at
all
A little
bit
A fair
bit
A
lot
nNot at
all
A little
bit
A fair
bit
A
lot
Z SE Std Z p
I feel proud to be Aboriginal
a
. 43 0 1 0 42 43 0 1 1 41 0.00 0.50 −1.00 0.317
How important is it for you to be recognised as an Aboriginal
a
person? 43 0 2 11 30 43 0 2 6 35 32.50 8.01 1.25 0.212
I have spent time trying to find out more about being Aboriginal
a
, such as the
history, traditions, and customs.
43 0 11 16 16 43 1 9 13 20 136.00 26.57 0.77 0.440
I feel a strong attachment towards my Aboriginal
a
Mob/Nation. 43 0 1 15 27 42 0 1 15 26 60.00 15.91 0.00 1.000
I feel a connection to my ancestors. 43 0 4 14 25 43 0 3 12 28 114.00 22.28 0.85 0.394
I am confident in speaking my language or words
b
25 3 15 5 2 26 4 14 4 4 33.00 8.70 0.63 0.527
It is important that I use my language or words
b
26 0 2 14 10 26 1 2 10 13 28.00 8.02 0.69 0.493
I feel good when I use my language or words
b
25 0 1 7 17 26 0 1 8 17 27.50 8.70 0.00 1.000
I am interested in keeping my language strong
b
26 0 1 1 24 27 0 0 5 22 6.00 3.35 −0.45 0.655
My family is interested in keeping my language strong
b
27 0 4 6 17 27 0 5 7 15 8.00 5.29 −1.13 0.257
My community is interested in keeping language strong
b
27 0 3 7 17 27 1 2 13 11 21.00 12.12 −1.48 0.138
a
Piped text was used in both the pre- and post-camp survey to replace the word ‘Aboriginal’above with each individual’s preferred cultural identity term.
b
Only respondents who indicated that they knew
at least a little Aboriginal or Torres Strait Islander words or language(s) completed these questions, reflected by smaller sample sizes for these comparisons.
Table 3: Pre-to post-camp tests of differences in cultural health and language indicators.
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at random (MAR). SPSS was used to impute missing
data for parametric tests using a fully conditional spec-
ification approach and five iterations. Analyses were
then re-run comparing the output of the observed data
to the combined imputed data following Rubin’s rule.
As shown in Supplementary Table S12, the mean dif-
ferences for t-tests computed with pooled imputed data
were consistent with those obtained using pairwise
deletion. The only difference was that the aARRQ total
score emerged as marginally significantly higher post-
camp compared to pre-camp following multiple impu-
tation (p = 0.048). Multiple imputation was not used to
impute data for non-parametric tests as non-parametric
data does not have variances that are properly weighted
to allow for imputation. Therefore, only complete-case
data is reported for Wilcoxon signed-rank tests in the
main results section above.
Discussion
The connections between Country, culture, and health
and wellbeing among Aboriginal peoples have been well
described and conceptualised.
3,8,12
Previous studies have
identified culture as a protective factor in Aboriginal
health and wellbeing.
32–34
However, measuring the
impact of meaningful and culturally centred initiatives
that address inequitable health outcomes among
Aboriginal peoples in Australia has received limited
attention. This has contributed to the gap between
empirical research and tangible and beneficial change.
35
Our work has built on established insights and sought to
develop empirical evidence regarding the value and
impact of a particular initiative focused on enhancing
health and wellbeing through strengthening connec-
tions with Country and culture. While the sample size
was smaller than anticipated, we have identified a range
of positive outcomes that warrant attention and will be
explored in further publications and initiatives.
Specifically, little research on cultural camps as a
platform and mechanism to improve Aboriginal health
and wellbeing exists in the Australian context.
17,36
Our
study is the first in the Australian context to measure the
impact of cultural camp attendance among Aboriginal
peoples. In the international context, there are a few
peer-reviewed studies that have measured the impact of
attending an indigenous cultural camp on participant
health or wellbeing.
19,26,37
Redvers and colleagues
19
explored the benefit of attending an urban land-based
Fig. 2: Perceived impacts of attending camp on cultural health indicators (N= 43).
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8 www.thelancet.com Vol 52 November, 2024
healing camp among Indigenous people at high risk of
homelessness and substance use living in Yellowknife,
Canada. Using a two-item feedback survey, they found
that people who spent time at the camp rated their
emotional wellbeing as better when leaving camp
compared to when arriving at camp. Their preliminary
study did not collect data on any other indicators of
health or wellbeing. Our Research Collaborative—which
centres existing, Aboriginal-led and run cultural camps
on Country at three locations in New South Wales—
involved far more extensive evaluation of the health and
wellbeing impacts of attending a cultural camp within a
sample of Aboriginal adults in Australia (see pre- and
post-camp surveys reported in the Supplementary
materials). Importantly, and as expected, we found
strong support for the format of camps as engaging (by
virtue of offering participation in a wide range of cul-
tural activities), enjoyable, and beneficial. Indeed, re-
spondents indicated strong participation in the full
spectrum of cultural activities we surveyed. Our results
have provided clarity to the concept of ‘cultural health’,
by evidencing measurable indicators that reflect how
previously abstract notions such as connectedness to
culture, Country, and mob, and strength in Aboriginal
cultural identity, act as protective factors in health and
wellbeing. The results presented in this paper are
mirrored in qualitative results that reflect the impor-
tance of cultural health through the voices of camp at-
tendees.
22
We also acknowledge that capturing data is
always imperfect and cannot account for the many other
ways in which culture is shared and expressed at camps
outside of what was asked about in the survey. Percep-
tions of the camp were exceptionally positive and there
was almost universal interest in attending again, sug-
gesting that this is a very promising format.
Through the process of conducting this study, and in
discussion with the Cultural Governance Group who
oversee this work, we gained valuable insight into
measurement approaches to health and wellbeing
among Aboriginal adults living in Australia that reiterate
the importance of flexibility noted in other international
contexts
19
and the use of measures developed specifically
for Aboriginal populations where available. We found
that common Western-derived measures used in this
study, including the CD-RISC measure of individual
resilience,
28
and the EQ-5D-5L measure of health-related
quality of life
29
were subject to ceiling and floor effects in
this sample, respectively. This means that on average,
the Aboriginal men and women in this study reported
very high individual resilience and very low health-
related quality of life complaints, with little capacity to
detect beneficial changes in either measure over time.
This suggests that these measures may not be suitable
for similar future work that aims to assess health-related
changes among non-clinical samples. Other recent work
with Aboriginal young people suggests that the CD-
RISC is not as strong of a predictor of wellbeing as
other socioemotional measures,
38
affirming the need to
consider alternative measures in future research.
However, we did find evidence that attending the
camps resulted in a small increase in perceived sources
of relational-community-cultural strength as a source of
resilience, measured using the adapted Aboriginal
Resilience and Recovery Questionnaire. This result
serves as tentative evidence for the unique relational
benefits of the camp format which facilitated intergen-
erational sharing and connection between people, as
well as connection to ancestors and Country. While this
result is encouraging, we acknowledge that the broad
concept of ‘resilience’is itself contested and can be
challenging for Aboriginal peoples. Indeed, there was a
robust discussion of the concept of ‘resilience’among
Aboriginal men and women who participated in the
yarning circle component of the broader Research
Collaborative. This will be the subject of a future paper
from this work.
The repeated measures items we designed to assess
changes in cultural health pre to post camp were also
subject to ceiling effects, with most respondents rating
themselves high on cultural health indicators both pre-
and post-camp. However, given the central importance
of cultural health indicators to this project, and the
flexibility that comes with designing our own cultural
health measure, we had the foresight to include differ-
ently worded post-camp items that would be able to
detect meaningful changes because of attending camp
even if pre-post items could not. This methodological
decision proved to be very valuable in revealing
Health-Related Quality of Life Domain Pre-camp problems, nPost-camp problems, nN Z Std Z SE p
None Slight Moderate Severe Extreme/
Unable
None Slight Moderate Severe Extreme/
Unable
Mobility 31 8 3 0 1 33 5 2 0 0 40 36.00 1.73 7.80 0.08
Self-care 42 0 0 0 0 38 0 1 0 0 39 1.00 1.00 0.50 0.32
Usual activities 33 7 2 1 0 35 3 2 0 0 40 3.50 −1.90 5.50 0.06
Pain 22 14 7 0 0 18 19 2 1 0 40 49.00 −0.24 14.00 0.81
Anxiety/depression 14 22 4 3 0 12 23 4 1 0 40 81.00 0.24 19.00 0.81
Table 4: Tests of differences in pre- and post-camp health-related quality of life measured using the EQ-5D-5L.
Articles
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otherwise undetectable and extremely positive impacts
of camp attendance on cultural health. These positive
results align well with the many stories we heard from
participants about how their connection to culture,
Country, and health more broadly was impacted in a
positive way by spending time at camp. Some of these
stories were shared in men’s and women’s yarning
circles conducted as a part of the broader Research
Collaborative.
22
Others were shared directly with the
knowledge holders who run the camps or other mem-
bers of the research team. These rich accounts are
critical to refining our approach to quantifying cultural
health in a manner true to those we study and will help
to inform our future work.
The principal limitation of this study is the smaller
than anticipated sample size which prevented us from
being able to explore camp impacts separately for men
and women while accounting for the potential impact of
covariates. Time spent on Country should be healing,
and implementing extensive evaluation procedures
within the camps may have risked undermining the
safety of the camp experiences. Others have noted that
Aboriginal communities may be resistant to evaluation
which can be seen as a colonial mandate undermining
the inherent value of Aboriginal ways of knowing, being
and doing.
39
With that in mind, we restricted survey data
collection to the weeks before the camp for the pre-camp
survey and the end of the final day of camp for the post-
camp survey. This approach meant that our data
collection did not impede on any of the cultural activities
at camp and prioritised the unobstructed experiences of
participants over data collection needs. However, this
approach also limited our capacity to collect post-camp
surveys from all research volunteers, which resulted in
the smaller than expected sample size in this study. We
speculate that a range of other factors may have further
contributed to reduced capacity to collect post-camp
survey data, including attendees having to deconstruct
the camps and clean the area before departure, and
people being anxious to return home with many trav-
eling hundreds of kilometres to/from camps. Another
limitation of this study is that the increase in familywise
error rate was not controlled across repeated statistical
tests. As noted elsewhere, we consider this research to
be preliminary and we encourage replication among
larger samples. Finally, providing a research incentive
always has the potential to bias responses with financial
reward, or intimate that the respondents should appease
the researchers by continuing to be involved. However,
we chose to offer a grocery voucher nonetheless, to
compensate participants for the time and labour. We
believe that streamlining our evaluation will be impor-
tant to improving response rates in future research.
Removing measures that may not be able to capture
meaningful change would be a reasonable first step.
We also had almost twice as many women completing
the surveys than men. This gender imbalance is not
unique to this study, with previous research showing that
men are more difficult to recruit into health interventions
and research.
40
Additionally, there were a greater number
of female research team members on site at camps which
may have contributed to a higher number of post-camp
surveys from those who attended the women’scamping
area.
We also acknowledge the possibility of bias toward
positive evaluations of the camp experience and camp
benefits given the sample consisted of people already
motivated to engage in a cultural camp on Country. That
said, this study represents the first in a very promising
new line of enquiry—Aboriginal-governed research
seeking to understand the immediate and longer-term
benefits of cultural camps for Aboriginal cultural
health in Australia. In the future, we seek to expand this
work among larger, more gender-balanced samples
implementing key learnings regarding the potential for
methodological improvement uncovered by this study.
It would be informative for future work to explore the
generalisability of the results across other Aboriginal
nations around Australia, and to integrate longer term
follow ups to investigate the persistence of benefits over
time. Additional work assessing the impact of repeated
camp attendance on indicators of cultural health (to
show ‘dose effect’) would also be highly valuable.
Nonetheless, we believe that our results offer compel-
ling preliminary evidence for Aboriginal-led strengths-
based approaches to supporting cultural health on
Country for Aboriginal adults with transparent meth-
odology and findings that can be adapted for other
contexts.
Conclusion
The Gaawaadhi Gadudha Research Collaborative
seeks to amplify Aboriginal ways of knowing, being
and doing by evaluating existing cultural camps on
Country that utilise traditional cultural knowledge and
healing practices to promote the cultural health of
Aboriginal men and women. Our evaluation process,
which was developed according to the needs and in-
terests of the knowledge holders who guide this work,
revealed promising preliminary evidence for the
impact of attending camps on cultural health, while
also uncovering opportunities for methodological
improvement in future research. The data presented
here, in concert with other papers in this special
collection,
20–22
highlights the Research Collaborative as
a proof-of-concept model for supporting Aboriginal
cultural health. Ultimately, we hope this work con-
tributes to accelerated and deepening interest in
strengths-based models promoting cultural health
both locally and internationally.
Contributors
BB: Conceptualisation; Methodology; Formal analysis; Investigation;
Writing—Original draft; Writing—review and editing; Project admin-
istration; Funding acquisition.
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10 www.thelancet.com Vol 52 November, 2024
AY: Conceptualisation; Methodology; Investigation; Writing—re-
view and editing; Supervision; Project administration; Funding
acquisition.
AZ: Methodology; Investigation; Writing—review and editing;
Funding acquisition.
JK: Methodology; Writing—Original draft; Writing—review and
editing; Funding acquisition.
MOL: Conceptualisation; Methodology; Supervision; Writing—re-
view and editing; Funding acquisition.
NS: Methodology; Investigation; Project administration; Writing—
review and editing.
SMT: Methodology; Writing—Original draft; Writing—review and
editing; Funding acquisition.
BJB: Methodology; Writing—reviewing and editing; Funding
acquisition.
TF: Conceptualisation; Methodology; Supervision; Writing—review
and editing; Funding acquisition.
WF: Conceptualisation; Methodology; Supervision; Writing—review
and editing; Funding acquisition.
BB and AY had access to the raw data. BB had final responsibility for
the decision to submit for publication.
Data sharing statement
The study protocol is available elsewhere.
8
The study materials are made
available in the Supplementary file. Individual participant data is not
made available to external parties.
Declaration of interests
The authors declare no conflicts of interest.
Acknowledgements
We would like to acknowledge all study participants who contributed
their time and data to this research. We acknowledge Wendy Jopson
who contributed to this project. BB is supported by Australian Research
Council Laureate Fellowship FL190100011.
Appendix A. Supplementary data
Supplementary data related to this article can be found at https://doi.
org/10.1016/j.lanwpc.2024.101200.
References
1Morrissey M, Pe-Pua R, Brown A, Latif A. Culture as a determinant
of aboriginal health. In: Anderson I, Baum F, Bentley M, eds.
Beyond bandaids: exploring the underlying social determinants of
aboriginal health. Papers from the social determinants of aboriginal
health workshop. Adelaide: Cooperative Research Centre for
Aboriginal Health, Darwin; 2007:239–254.
2 Veth P, Ward I, Manne T, et al. Early human occupation of a
maritime desert, Barrow Island, North-West Australia. Quat Sci
Rev. 2017;168:19–29. https://doi.org/10.1016/j.quascirev.2017.05.
002.
3 Thorpe A, Yashadhana A, Biles B, Munro-Harrison E, Kingsley J.
Indigenous health and connection to country. In: Oxford Research
Encyclopedia of Global Public Health. 2023. https://doi.org/10.1093/
acrefore/9780190632366.013.436.
4Kingsley J, Munro-Harrison E, Jenkins A, Thorpe A. “Here we are
part of a living culture”: understanding the cultural determinants of
health in Aboriginal gathering places in Victoria, Australia. Health
Place. 2018;54:210–220.
5Kingsley J, Munro-Harrison E, Jenkins A, Thorpe A. Developing a
framework identifying the outcomes, principles and enablers of
“gathering places”: perspectives from Aboriginal people in Victoria,
Australia. Soc Sci Med. 2021;283:114217.
6Hunter LM, Logan J, Goulet JG, Barton S. Aboriginal healing:
regaining balance and culture. J Transcult Nurs. 2006;17(1):13–22.
7Oster RT, Grier A, Lightning R, Mayan MJ, Toth EL. Cultural
continuity, traditional Indigenous language, and diabetes in Alberta
First Nations: a mixed methods study. Int J Equity Health.
2014;13(2014):92.
8 Yashadhana A, Zwi AB, Brady B, et al. Gaawaadhi Gadudha: un-
derstanding how cultural camps impact health, wellbeing, and
resilience among Aboriginal adults in New South Wales (Australia)
–a collaborative study protocol. BMJ Open. 2023;13:e073551.
https://doi.org/10.1136/bmjopen-2023-073551.
9The Lowitja Institute. Cooperative research centre for Aboriginal
and Torres Strait Islander health. Melbourne: Aboriginal and
Torres Strait Islander Health Cooperative Research Centre;
2014.
10 Arnold C, Atchison J, McKnight A. Reciprocal relationships with
trees: rekindling Indigenous wellbeing and identity through the
Yuin ontology of oneness. Aust Geogr. 2021;52(2):131–147.
11 Galway LP, Esquega E, Jones-Casey K. “Land is everything, land is
us”: exploring the connections between climate change, land, and
health in Fort William First Nation. Soc Sci Med. 2022;294:
114700.
12 Fatima Y, Liu Y, Cleary A, et al. Connecting the health of country
with the health of people: application of “caring for country”in
improving the social and emotional well-being of Indigenous
people in Australia and New Zealand. The Lancet Regional
Health Western Pacific. Lancet Reg Health Western Pac. 2023;31:
100648.
13 Kingsley J, Aldous D, Townsend M, Phillips R, Henderson-
Wilson C. Investigating health, economic and socio-political factors
that need consideration when establishing Victorian Aboriginal
land management projects. Australas J Environ Manag. 2009;16(2):
113–123.
14 Gee G, Hulbert C, Kennedy H, et al. Development of an Aboriginal
Resilience and Recovery Questionnaire–a collaboration between
practitioners and help-seeking clients of a Victorian Aboriginal
community controlled health service. BMC Med Res Methodol.
2023;23(1):290.
15 Usher K, Jackson D, Walker R, et al. Indigenous resilience in
Australia: a scoping review using a reflective decolonizing collective
dialogue. Front Public Health. 2021;9:630601.
16 Fleming J, Ledogar RJ. Resilience, an evolving concept: a review of
literature relevant to Aboriginal research. Pimatisiwin. 2008;6(2):7.
17 Dobia B, Bodkin-Andrews G, Parada RH, et al. Aboriginal girls circle:
enhancing connectedness and promoting resilience for aboriginal girls:
final pilot report. 2013.
18 Yashadhana A, Fields T, Liu E, et al. Therapeutic aspects of
Connection to Country and cultural landscapes among Aboriginal
peoples from the Stolen Generations living in urban NSW,
Australia. Public Health Res Pract. 2023;33(4):3342332.
19 Redvers N, Nadeau M, Prince D. Urban land-based healing: a
northern intervention strategy. Int J Indig Health. 2021;16(2):322–
337.
20 Fields T, Foster W, Biles BJ, Yashadhana Y. Redefining the gap in
Aboriginal health: from deficit to cultural connection. Lancet Reg
Health Western Pac. 2024:101176.
21 Biles BJ, Serova N, Stanbrook G, et al. What is Indigenous cultural
health and wellbeing? A narrative literature review. Lancet Reg
Health Western Pac. 2024:101220.
22 Yashadhana A, Biles BJ, Serova N, et al. Gaawaadhi Gadudha:
exploring how cultural camps support health and wellbeing among
Aboriginal adults in New South Wales Australia, a qualitative study.
Lancet Reg Health Western Pac. 2024:101208.
23 Chow S-C, Shao J, Wang H. Sample size calculations in clinical
research. 2nd ed. Boca Raton: Chapman & Hall/CRC; 2008. Section
3.1.1, page 50.
24 Qualtrics. Version: October 2022 –December 2023. Provo, Utah, USA;
2005. Available at: https://www.qualtrics.com.
25 Jones R, Thurber KA, Chapman J, et al. Study protocol: our cultures
count, the Mayi Kuwayu study, a national longitudinal study of
aboriginal and Torres Strait Islander wellbeing. BMJ Open. 2018;8:
e023861. https://doi.org/10.1136/bmjopen-2018-023861.
26 Snowshoe A, Crooks CV, Tremblay PF, et al. Cultural connected-
ness and its relation to mental wellness for first nations youth.
J Prim Prev. 2017;38:67–86. https://doi.org/10.1007/s10935-016-
0454-3.
27 Gee GJ. Resilience and recovery from trauma among Aboriginal help
seeking clients in an urban Aboriginal community controlled health
organisation (Doctoral dissertation), University of Melbourne, Mel-
bourne School of Psychological Sciences. 2016.
28 Connor KM, Davidson JR. Development of a new resilience scale:
the Connor-Davidson resilience scale (CD-RISC). Depress Anxiety.
2003;18(2):76–82.
29 Herdman M, Gudex C, Lloyd A, et al. Development and pre-
liminary testing of the new five-level version of EQ-5D (EQ-5D-5L).
Qual Life Res. 2011;20:1727–1736.
Articles
www.thelancet.com Vol 52 November, 2024 11
30 Ribeiro Santiago PH, Haag D, Macedo DM, et al. Psychometric
properties of the EQ-5D-5L for aboriginal Australians: a multi-
method study. Health Qual Life Outcome. 2021;19:1–16.
31 IBM Corp. Released. IBM SPSS statistics for Windows, version 26.0.
Armonk, NY: IBM Corp; 2019.
32 Rowley KG, O’DeaK,AndersonI,etal.Lowerthanexpectedmorbidity
and mortality for an Australian aboriginal population: 10-year f ollow-
up in a decentralised community. Med J Aust. 2008;188:283–287.
https://doi.org/10.5694/j.1326-5377.2008.tb01621.x.
33 Burgess CP, Johnston FH, Bowman DMJS, et al. Healthy country:
healthy people? Exploring the health benefits of indigenous natural
resource management. Aust N Z J Public Health. 2005;29:117–122.
https://doi.org/10.1111/j.1467-842x.2005.tb00060.x.
34 Kelly K, Dudgeon P, Gee G, et al. Living on the edge: social and
emotional wellbeing and risk and protective factors for serious psy-
chological distress among Aboriginal and Torres Strait Islander people.
Darwin: Cooperative Research Centre for Aboriginal Health;
2009.
35 Bainbridge R, Tsey K, McCalman J, et al. No one’s discussing the
elephant in the room: contemplating questions of research impact
and benefit in Aboriginal and Torres Strait Islander Australian
health research. BMC Publ Health. 2015;15(1):696.
36 Ngurra D, Dadd L, Norman-Dadd C, et al. Buran Nalgarra: an
Indigenous-led model for walking with good spirit and learning
together on Darug Ngurra. Alternative. 2021;17(3):357–367.
37 Barnett JD, Schmidt TC, Trainor B, Wexler L. A pilot evaluation of
culture camps to increase Alaska native youth wellness. Health
Promot Pract. 2020;21(3):363–371. https://doi.org/10.1177/1524839
918824078.
38 Robinson G, Lee E, Leckni ng B, Silburn S, Nagel T, Midford R.
Validity and reliability of resiliency measures trialled for the
evaluation of a preventative Resilience-promoting social-
emotional curriculum for remote Aboriginal school students.
PLoS One. 2022;17(1):e0262406. https://doi.org/10.1371/journal.
pone.0262406.
39 Wilson K. Therapeutic landscapes and First Nations peoples: an
exploration of culture, health and place. Health Place. 2003;9(2):83–93.
40 Ryan J, Lopian L, Le B, et al. It’s not raining men: a mixed-methods
study investigating methods of improving male recruitment to
health behaviour research. BMC Publ Health. 2019;19:814.
Articles
12 www.thelancet.com Vol 52 November, 2024