The cultural adaptation and evaluation of Healthy Dads Healthy Kids for Aboriginal fathers and their children living on Darkinjung Country

<p dir="ltr">Background</p><p dir="ltr">Aboriginal men experience the worst health outcomes of any population group in Australia. Despite the fact that Aboriginal men are nearly three-times more likely to develop cardiovascular disease than non-Aboriginal men and have a life expectancy that is a decade shorter, there is a persistent lack of recognition given to the social determinants influencing these outcomes. Historic experiences of colonisation and ongoing discrimination such as the dispossession of traditional lands, restriction of cultural knowledge transmission, and the forced removal of children continue to impact the health and wellbeing of Aboriginal men. These experiences have diminished the confidence of Aboriginal men to lead in their communities and fulfill their parenting roles. Whilst Aboriginal men have shown a desire for parenting support that encourages healing, cultural connection, and strong relationships with children, relevant support is scarce. Although fathers are generally underrepresented in parenting research, the experiences of Aboriginal fathers have rarely been reported which has resulted in policies, programs and practices that do not meet the needs of Aboriginal men.</p><p dir="ltr">The Healthy Dads Healthy Kids (HDHK) program has been successfully implemented in a range of contexts in Australia and internationally. Empirical evaluations have shown that the HDHK program has resulted in weight reduction in fathers, increased physical activity levels in children, and improved father-child relationships. However, a comprehensive, strengths- based, community-led cultural adaptation process to design a program for Aboriginal fathers and their children has not been reported. Objectives</p><p dir="ltr">The primary aim of this thesis was to evaluate the impact of a culturally adapted Healthy Dads Healthy Kids program for Aboriginal fathers and their children living on Darkinjung Country. This thesis also presents a series of studies investigating three secondary aims, which are briefly described below. As these studies provide important context for the primary analysis, the secondary aims are presented first in this thesis, in the following order:</p><p dir="ltr">Secondary aim 1: Report on the participation of Aboriginal and Torres Strait Islander families in Australian parenting programs</p><p dir="ltr">To investigate this aim, a systematic scoping review with no date restrictions across four databases was undertaken to assess the inclusion of Aboriginal and Torres Strait Islander parents in randomised control trials of parenting programs in Australia. Of all 109 studies that met the inclusion criteria, only nine recorded Indigenous Australian status of participants, with only 93 participants across these studies being reported as Indigenous, and no study reporting the involvement of Indigenous men. Only two studies included in the review reported consulting with Indigenous people, and no study reported including strategies to recruit Indigenous people.</p><p dir="ltr">Secondary aim 2: Understand the roles and experiences of Aboriginal fathers and father figures living on Darkinjung Country</p><p dir="ltr">To address this aim, yarning methodology was employed with members of the Eleanor Duncan Aboriginal Services Men's Group. Findings indicate that Aboriginal men living on Darkinjung Country require culturally responsive health and parenting support. Unique factors specific to the lived experiences of Aboriginal people are still impacting Aboriginal fathers and father figures in fulfilling their parenting roles. Those providing parenting support for Aboriginal fathers must acknowledge their inherent strengths, including leadership in communal health, cultural knowledge transmission, and the modelling of positive familial behaviours to children.</p><p dir="ltr">Secondary aim 3: Report the process and outcomes of a systematic approach to culturally adapt the Healthy Dads Healthy Kids program for Aboriginal fathers and their children living on Darkinjung Country</p><p dir="ltr">To achieve this aim, the Ecological Validity Model was employed to culturally adapt the original Healthy Dads Healthy Kids program. This process included codesign methods in partnership with a community panel consisting of members of the Eleanor Duncan Aboriginal Services Men's Group, and cultural governance from a cultural affirmation panel consisting of key community stakeholders. The cultural adaptation process resulted in the development of the biya yadha gudjagang yadha: Healthy Dads Healthy Mob program. Significant adaptations included reorienting program outcomes to focus on father and child social and emotional health over physical measures, and including new content themes such as cultural identity, wellbeing, and Aboriginal role models that did not exist in the original program.</p><p dir="ltr">Primary aim: Evaluate the impact of a culturally adapted Healthy Dads Healthy Kids (HDHK) program for Aboriginal fathers and their children living on Darkinjung Country</p><p dir="ltr">To address this aim, a single arm, pre-post feasibility trial including qualitative (yarning) and quantitative (survey & anthropometry) measures assessing the biya yadha gudjagang yadha: Healthy Dads Healthy Mob program was conducted. The program was implemented at Eleanor Duncan Aboriginal Services on Darkinjung Country over a 9-week period with Aboriginal fathers and their children. Program feasibility was confirmed with high levels of program attendance, retention, and participant satisfaction. The program led to some positive preliminary outcomes. Large effect sizes were evident for most assessed outcomes in both fathers and children, which was supported by very positive qualitative feedback from participants.</p><p dir="ltr">Discussion</p><p dir="ltr">Aboriginal fathers have been significantly under-represented in family-based parenting programs, very little has been published on the roles, experiences and needs of Aboriginal men, and there remains a scarcity of culturally relevant parenting programs available. This thesis demonstrated that by centering the voices of Aboriginal men, embedding Aboriginal-led cultural governance, Aboriginal research leadership, and applying a culturally sensitive adaptation framework can create a culturally responsive parenting program that is feasible, acceptable, and improves health and wellbeing outcomes for Aboriginal fathers and their children, thus supporting the primary hypothesis. In addition, this thesis highlighted the inattention given to the involvement of Aboriginal and Torres Strait Islander families in previous Australian parenting trials, provided a deeper understanding of the roles, experiences, and needs of Aboriginal fathers, and reported the process and outcomes of a systematic approach to culturally adapt the Healthy Dads Healthy Kids program for Aboriginal fathers and their children living on Darkinjung Country. Research findings indicate that the positive indicators of preliminary efficacy reported in this thesis should be evaluated in a larger, fully powered trial.</p><p dir="ltr">al men experience the worst health outcomes of any population group in Australia. Despite the fact that Aboriginal men are nearly three-times more likely to develop cardiovascular disease than non-Aboriginal men and have a life expectancy that is a decade shorter, there is a persistent lack of recognition given to the social determinants influencing these outcomes. Historic experiences of colonisation and ongoing discrimination such as the dispossession of traditional lands, restriction of cultural knowledge transmission, and the forced removal of children continue to impact the health and wellbeing of Aboriginal men. These experiences have diminished the confidence of Aboriginal men to lead in their communities and fulfill their parenting roles. Whilst Aboriginal men have shown a desire for parenting support that encourages healing, cultural connection, and strong relationships with children, relevant support is scarce. Although fathers are generally underrepresented in parenting research, the experiences of Aboriginal fathers have rarely been reported which has resulted in policies, programs and practices that do not meet the needs of Aboriginal men.</p><p dir="ltr">The Healthy Dads Healthy Kids (HDHK) program has been successfully implemented in a range of contexts in Australia and internationally. Empirical evaluations have shown that the HDHK program has resulted in weight reduction in fathers, increased physical activity levels in children, and improved father-child relationships. However, a comprehensive, strengths- based, community-led cultural adaptation process to design a program for Aboriginal fathers and their children has not been reported. Objectives</p><p dir="ltr">The primary aim of this thesis was to evaluate the impact of a culturally adapted Healthy Dads Healthy Kids program for Aboriginal fathers and their children living on Darkinjung Country. This thesis also presents a series of studies investigating three secondary aims, which are briefly described below. As these studies provide important context for the primary analysis, the secondary aims are presented first in this thesis, in the following order:</p><p dir="ltr">Secondary aim 1: Report on the participation of Aboriginal and Torres Strait Islander families in Australian parenting programs</p><p dir="ltr">To investigate this aim, a systematic scoping review with no date restrictions across four databases was undertaken to assess the inclusion of Aboriginal and Torres Strait Islander parents in randomised control trials of parenting programs in Australia. Of all 109 studies that met the inclusion criteria, only nine recorded Indigenous Australian status of participants, with only 93 participants across these studies being reported as Indigenous, and no study reporting the involvement of Indigenous men. Only two studies included in the review reported consulting with Indigenous people, and no study reported including strategies to recruit Indigenous people.</p><p dir="ltr">Secondary aim 2: Understand the roles and experiences of Aboriginal fathers and father figures living on Darkinjung Country</p><p dir="ltr">To address this aim, yarning methodology was employed with members of the Eleanor Duncan Aboriginal Services Men's Group. Findings indicate that Aboriginal men living on Darkinjung Country require culturally responsive health and parenting support. Unique factors specific to the lived experiences of Aboriginal people are still impacting Aboriginal fathers and father figures in fulfilling their parenting roles. Those providing parenting support for Aboriginal fathers must acknowledge their inherent strengths, including leadership in communal health, cultural knowledge transmission, and the modelling of positive familial behaviours to children.</p><p dir="ltr">Secondary aim 3: Report the process and outcomes of a systematic approach to culturally adapt the Healthy Dads Healthy Kids program for Aboriginal fathers and their children living on Darkinjung Country</p><p dir="ltr">To achieve this aim, the Ecological Validity Model was employed to culturally adapt the original Healthy Dads Healthy Kids program. This process included codesign methods in partnership with a community panel consisting of members of the Eleanor Duncan Aboriginal Services Men's Group, and cultural governance from a cultural affirmation panel consisting of key community stakeholders. The cultural adaptation process resulted in the development of the biya yadha gudjagang yadha: Healthy Dads Healthy Mob program. Significant adaptations included reorienting program outcomes to focus on father and child social and emotional health over physical measures, and including new content themes such as cultural identity, wellbeing, and Aboriginal role models that did not exist in the original program.</p><p dir="ltr">Primary aim: Evaluate the impact of a culturally adapted Healthy Dads Healthy Kids (HDHK) program for Aboriginal fathers and their children living on Darkinjung Country</p><p dir="ltr">To address this aim, a single arm, pre-post feasibility trial including qualitative (yarning) and quantitative (survey & anthropometry) measures assessing the biya yadha gudjagang yadha: Healthy Dads Healthy Mob program was conducted. The program was implemented at Eleanor Duncan Aboriginal Services on Darkinjung Country over a 9-week period with Aboriginal fathers and their children. Program feasibility was confirmed with high levels of program attendance, retention, and participant satisfaction. The program led to some positive preliminary outcomes. Large effect sizes were evident for most assessed outcomes in both fathers and children, which was supported by very positive qualitative feedback from participants.</p><p dir="ltr">Discussion</p><p dir="ltr">Aboriginal fathers have been significantly under-represented in family-based parenting programs, very little has been published on the roles, experiences and needs of Aboriginal men, and there remains a scarcity of culturally relevant parenting programs available. This thesis demonstrated that by centering the voices of Aboriginal men, embedding Aboriginal-led cultural governance, Aboriginal research leadership, and applying a culturally sensitive adaptation framework can create a culturally responsive parenting program that is feasible, acceptable, and improves health and wellbeing outcomes for Aboriginal fathers and their children, thus supporting the primary hypothesis. In addition, this thesis highlighted the inattention given to the involvement of Aboriginal and Torres Strait Islander families in previous Australian parenting trials, provided a deeper understanding of the roles, experiences, and needs of Aboriginal fathers, and reported the process and outcomes of a systematic approach to culturally adapt the Healthy Dads Healthy Kids program for Aboriginal fathers and their children living on Darkinjung Country. Research findings indicate that the positive indicators of preliminary efficacy reported in this thesis should be evaluated in a larger, fully powered trial.</p>