Exposure to the Family Wellbeing program and associations with empowerment, health, family and cultural wellbeing outcomes for Aboriginal and Torres Strait Islander peoples: a cross-sectional analysis | BMC Public Health

Mayi Kuwayu: The National Study of Aboriginal and Torres Strait Islander Wellbeing (the Mayi Kuwayu Study) is a longitudinal study that has been designed to quantify the links between social and cultural determinants, such as cultural expression, community decision making and family connection, to health and wellbeing [8, 9]. It is the largest prospective cohort study of Aboriginal and Torres Strait Islander peoples in Australia. The study is open to participation by Aboriginal and Torres Strait Islander adults aged 16 and over and commenced recruitment in 2018. Participants were recruited via mixed methods, including through the Medicare, through in-community recruitment or through online questionnaire [20]. All Mayi Kuwayu Study data included in the current analysis were based on self-reported responses, with the exception of remoteness, which was derived from postcode.

This cross-sectional analysis is conducted using the third release (R.3) of the Mayi Kuwayu baseline data (N = 9,843), and includes all responses received between 2018-December 2020. FWB participants are identified by a question asking ‘Have you ever participated in: the Family Wellbeing Program?’, non-FWB were any survey participant who did not select the “Family Wellbeing Program” option. No information was collected on the date of participation in the program.

The measures of culture and wellbeing have been developed through extensive research led by Aboriginal and Torres Strait Islander people including extensive partnerships, consultation and field testing with communities [8, 9, 21, 22].

Governance and ethics

The study is overseen by an Aboriginal and Torres Strait Islander governance group consisting of peak Aboriginal and Torres Strait Islander health organisations. In addition, all data use is assessed according to Indigenous Data Sovereignty principles and approved by an independent Indigenous Data Governance committee, known as the Mayi Kuwayu Data Governance Committee (Approval Reference No. D210511). The research was conducted with ethics approvals from relevant Aboriginal and Torres Strait Islander organisations, and from national, state and territory Human Research Ethics Committees (HRECs).

Variables

Exposure variable (FWB participation)

Family Wellbeing participants are identified through Mayi Kuwayu question. ‘Have you ever participated in: Family Wellbeing Program’.

Outcome variables

Outcome variables used in the study were selected based on analysis of the literature, including previous evaluations of the program [16, 17, 23] and feedback from program providers. They are designed to provide indicators across personal, organisational and community empowerment, and health outcomes (see Appendix 1).

Personal empowerment

Personal empowerment was measured with responses to the question, “how much are you in control of your life?”’, with response options “A lot”, “A fair bit”, “A little bit” and “Not at all”. These were then dichotomised as a (0) not at all and (1) little—a lot. Life satisfaction was measured according to responses to the question, “How satisfied are you with your life?”, with response options “a lot”, “a fair bit”, “a little bit” and “not at all”. These were then categorized as a (0) not at all and (1) little to a lot. General health was measured according to the question “How would you rate your general health?”; response options were “poor”, “fair”, “good”, “very good” or “excellent”. Responses were categorised as (0) poor-fair and (1) good–excellent.

Family functioning was measured according to a composite score of responses to a set of nine questions asking “In my family…”, “We get together and cope in the hard times”, “we celebrate special days/ events”, “we talk with each other about the things that matter”, “we are always there for each other”, “we manage money well”, “we have common interests”, “people are accepted for who they are”, “we have good support from mob”, “we have family knowledge and traditions that we pass on to our children”. With response options “not at all” (1), “a little bit” (2), “a fair bit” (3) to “a lot” (4), and “unsure” (0). Responses were summed (range: 0–36), and participants were categorized as having (0) low- moderate family functionality (score 0–29) or (1) high family functionality (score 30–36). Responses to the nine questions were summed for participants with complete data only; participants missing responses to any of the questions were coded as missing. All outcome measures above were coded as binary for use in the regression analysis.

Organisational empowerment

For organisational empowerment a composite score of the cultural knowledge and practice subset was created, that includes questions relating to contribution to community and participation in community-based events. The score was made up of responses to ten questions, summed together to generate a total cultural wellbeing score ranging from zero to 40. The questions asked “How much time do you spend…” 1. “With someone who has cultural knowledge (elder or knowledge holder)?” 2. “Learning and using knowledge from Aboriginal/Torres Strait Islander Law (or Lore)?” 3. “On country?” 4. “Getting or eating bush tucker (includes traditional foods and fishing)?” 5. “Learning culture, kinship and respect?” 6. “Making art, music or painting?” 7. “Passing on cultural knowledge?” 8. “Participating in social events related to Aboriginal/Torres Strait Islander people (such as NAIDOC week, Sorry Day events, cultural festivals, corrobboree, marches or rallies)?” 9. “Contributing to your community (such as participating in community meetings, organising events, volunteering, healing, being on committees or boards)?” 10. “Receiving Aboriginal/Torres Strait Islander healing methods (such as traditional healers, bush medicine)?”. With response options “Not at all” (1), “A little bit” (2), “A fair bit” (3) and “A lot” (4). Responses for the 10 questions were summed together to generate a total cultural wellbeing score ranging from zero to 40; participants missing any data had their score coded as missing. A binary category was created of (0) low cultural wellbeing (scores of less than or equal to 15) and (1) high cultural wellbeing (scores between 15 and 40).

Community empowerment

Decision making was measured by the question “in the Aboriginal and/ or Torres Strait Islander community where I live now local Aboriginal and Torres Strait Islander people make community decisions” with response options “Not at all”, “A little bit”, “A fair bit”, “A lot” and “Unsure”. Responses were coded and categorised to (0) not at all (Not at all) and (1) A little – a lot; unsure was coded as missing.

Health seeking and health risk factors and wellbeing variable

The presence of a drug and/ or alcohol problem was measured by response to the question that asked, “has a doctor ever told you that you have…drug or alcohol problem” with responses “no” and “yes”. Participants were also asked “do you drink alcohol?” with responses categorised as “current drinker”, “ex-drinker” and “never drinker”. Current smoker was measured with response to question “Do you smoke?”, with response categories created for “current smoker”, ex-smoker” and “never smoker”. Current smokers were also asked “do you want to quit smoking?” with five response options that were categorised as “not at all or unsure” and “a little to a lot”. For exercise in the past week where participants were asked to select the days that they did 30 or more minutes of exercise (Monday – Sunday) the responses (1 for each day selected) were summed into three categories “none”, “1–2 days” and “3 or more”.

Demographic variables

Eight demographic variables were used in the study including gender, age, location, and education. Following consultation with FWB providers we added measures for incarceration, low income, being removed as a child (Stolen^{Footnote 1}) and household overcrowding, as these were priority groups for the program over the last 30 years. Gender was coded according to response of “male” or “female”, with “other” coded as missing due to the small number of responses. Age was recoded into three age categories “16 to 34 years”, “35 to 54 years”, and “55 + years”. Education was recoded into two categories “Year 10 or below” (no school, primary school, some high school, and year 10) and “Year 12 or above” (Year 12, certificate or diploma and university). For the location variable the categories were collapsed to, “regional” (inner regional and outer regional), “remote” (remote and very remote) and “major cities” (major cities). Incarceration was measured from participant response to the question “Have you ever been in prison or youth detention?”, with categories created for “no prison or youth detention”, “prison”, “youth detention”, “youth detention and prison”; participants in the “prison and youth detention category” were omitted from the single response “prison” and “youth detention” categories. Family financial status was measured from response to the question of “which words best describe your family’s money situation?” with the six response options collapsed to the categories of “we have enough” ( we have a lot of savings, we have some savings and we have just enough to get us to the next payday) and “we don’t have enough” (we run out of money before payday, we are spending more than we get); the response of unsure was coded as missing. Participants were asked ‘Is where you live crowded?’ with five response options collapsed to “Not at all” and “a little to a lot”, the response not relevant was coded as missing. Stolen generation was measured with response to the question “were any of these people Stolen? With response options of “I was Stolen” or “I was not Stolen”.

Statistical analysis

A descriptive analysis is provided of the socio-demographic variables (Table 2), health risk factors and behaviours (Table 3) and empowerment outcome (Table 4) presented as percentage and number (%, n) overall and by FWB exposure. A Chi-square statistic was calculated to test for significant differences between FWB exposure and the categories of each demographic variable (Table 5).

Logistic regression was performed to examine the association between FWB participation and each outcome. Prevalence Ratios (PRs) and 95% Confidence Intervals (CIs) are presented for each exposure/outcome association. Models are presented unadjusted and adjusted accounting for gender, age, location and being an ex-drinker as these were conceptually thought to be linked to both exposure and outcome variables. A sensitivity analysis was conducted to address possible contamination within the analysis with Family Wellbeing Services [24] run by the Queensland Government. Analysis that included, and then excluded, all Queensland Family Wellbeing participants was run. Participants with missing data on each outcome of interest were excluded from the study. Analysis was conducted using Stata 16 [25].