Advertisement

Using participatory action research to co-design perinatal support strategies for Aboriginal and Torres Strait Islander parents experiencing complex trauma

Open AccessPublished:December 24, 2021DOI:https://doi.org/10.1016/j.wombi.2021.12.005

      Abstract

      Problem & background

      Support is important for all parents but critical for those experiencing complex trauma. The The Healing the Past by Nurturing the Future project uses participatory action research to co-design effective perinatal support for Aboriginal and Torres Strait Islander parents.

      Aim

      This research aims to identify and refine culturally appropriate support strategies for Aboriginal and Torres Strait Islander parents experiencing complex trauma.

      Design

      We presented our synthesised eight parent support goals and 60 strategies, collated from Elder and parent focus groups, previous participatory workshops, and evidence reviews, for discussion at a stakeholder workshop. Stakeholder perspectives were captured using a three-point agreement activity and, self- and scribe-recorded comments. Aboriginal and non-Aboriginal researchers analysised the qualitative data, to identify core factors which might facilitate or help enact the parenting related goals.

      Findings

      Overall, stakeholders (n = 37) strongly endorsed all eight goals. Workshop attendees (57% Aboriginal) represented multiple stakeholder roles including Elder, parent and service provider. Four core factors were identified as crucial for supporting parents to heal from complex trauma: Culture (cultural traditions, practices and strengths), Relationality (family, individual, community and services), Safety (frameworks, choice and control) and Timing (the right time socio-emotionally and stage of parenting).

      Discussion

      Context-specific support tailored to the Culture, Relationality, Safety, and Timing needs of parents is essential. These four factors are important elements to help enact or facilitate parenting support strategies.

      Conclusion

      Further work is now required to develop practical resources for parents, and to implement and evaluate these strategies in perinatal care to address cumulative and compounding cycles of intergenerational trauma.

      Abbreviations:

      HPNF (Healing the Past by Nurturing the Future)

      Keywords

      Statement of significance

      Problem or issue
      Perinatal programs for Aboriginal and Torres Strait Islander parents require culturally appropriate and feasible support strategies.
      What is already known
      Historical or childhood trauma can affect the health and wellbeing of Aboriginal and Torres Strait Islander parents and may contribute to intergenerational trauma.
      What this paper adds
      Four factors of Culture, Relationality, Safety, and Timing were identified by this study as important elements to help enact or facilitate parenting support strategies.

      1. Introduction

      The provision of equitable healthcare and social support for parents is a global public health priority to improve outcomes for children and families [
      • Barlow J.
      • Coren E.
      The effectiveness of parenting programs: a review of Campbell reviews.
      ,
      • Pierron A.
      • Fond-Harmant L.
      • Laurent A.
      • Alla F.
      Supporting parenting to address social inequalities in health: a synthesis of systematic reviews.
      ]. Becoming a parent is often a joyful time of personal growth and optimism for the future [
      • Chamberlain C.
      • Gee G.
      • Brown S.J.
      • et al.
      Healing the Past by Nurturing the Future—co-designing perinatal strategies for Aboriginal and Torres Strait Islander parents experiencing complex trauma: framework and protocol for a community-based participatory action research study.
      ,
      • Sexton M.B.
      • Bennett D.C.
      • Muzik M.
      • Rosenblum K.L.
      Resilience, recovery, and therapeutic interventions for peripartum women with histories of trauma.
      ]. However, the parenting transition can also be challenging [
      • Chamberlain C.
      • Gee G.
      • Harfield S.
      • et al.
      Parenting after a history of childhood maltreatment: a scoping review and map of evidence in the perinatal period.
      ]. Stress for First Nations parents can be increased due to intergenerational trauma, and the ongoing effects of colonisation and racialised policies and practices [
      • Chamberlain C.
      • Gee G.
      • Harfield S.
      • et al.
      Parenting after a history of childhood maltreatment: a scoping review and map of evidence in the perinatal period.
      ,
      • Cromer L.D.
      • Gray M.E.
      • Vasquez L.
      • Freyd J.J.
      The relationship of acculturation to historical loss awareness, institutional betrayal, and the intergenerational transmission of trauma in the American Indian experience.
      ,
      • Gatwiri K.
      • Rotumah D.
      • Rix E.
      Black lives matter in healthcare: racism and implications for health inequity among Aboriginal and Torres Strait Islander Peoples in Australia.
      ]. For example, many Aboriginal and Torres Strait Islander families and communities have experienced histories that involved widespread violence and massacres, dismantling of culture, land loss, displacement, assimilation, prohibition on the use of traditional language, punitive legal and social policies, and child removal practices, resulting in multiple childhood traumas [
      • Cromer L.D.
      • Gray M.E.
      • Vasquez L.
      • Freyd J.J.
      The relationship of acculturation to historical loss awareness, institutional betrayal, and the intergenerational transmission of trauma in the American Indian experience.
      ,
      • Chamberlain C.
      • Gee G.
      • Gartland D.
      • et al.
      Community perspectives of complex trauma assessment for Aboriginal parents: ‘its important, but how these discussions are held is critical’.
      ].
      Parents with histories of childhood trauma demonstrate resilience via the development of a wide range of coping skills. Parents may also experience complex posttraumatic stress related responses and patterns of distress (complex trauma) [
      • Fava N.M.
      • Simon V.A.
      • Smith E.
      • et al.
      Perceptions of general and parenting-specific posttraumatic change among postpartum mothers with histories of childhood maltreatment.
      ,
      • Brewin C.R.
      • Cloitre M.
      • Hyland P.
      • et al.
      A review of current evidence regarding the ICD-11 proposals for diagnosing PTSD and complex PTSD.
      ]. Trauma responses can be triggered during pregnancy and early parenting due to the intimate nature of pregnancy, birth, breastfeeding and the anxieties of having a new baby [
      • Chamberlain C.
      • Gee G.
      • Brown S.J.
      • et al.
      Healing the Past by Nurturing the Future—co-designing perinatal strategies for Aboriginal and Torres Strait Islander parents experiencing complex trauma: framework and protocol for a community-based participatory action research study.
      ,
      • Chamberlain C.
      • Ralph N.
      • Hokke S.
      • et al.
      Healing The Past By Nurturing The Future: a qualitative systematic review and meta-synthesis of pregnancy, birth and early postpartum experiences and views of parents with a history of childhood maltreatment.
      ,
      • Berthelot N.
      • Lemieux R.
      • Lacharité C.
      Development of a prenatal program for adults with personal histories of childhood abuse or neglect: a Delphi consensus consultation study.
      ]. Complex trauma responses are characterised by symptoms associated with posttraumatic stress disorder (re-experiencing, avoidance, and persistent sense of threat), in combination with a cluster of symptoms that collectively represent disturbances in self-organisation (affective dysregulation, negative self-concept and difficulties in relationships) [
      • Cloitre M.
      • Shevlin M.
      • Brewin C.R.
      • et al.
      The International Trauma Questionnaire: development of a self‐report measure of ICD‐11 PTSD and complex PTSD.
      ,
      • Erickson N.
      • Julian M.
      • Muzik M.
      Perinatal depression, PTSD, and trauma: impact on mother–infant attachment and interventions to mitigate the transmission of risk.
      ,
      • Frost R.
      • Hyland P.
      • Shevlin M.
      • Murphy J.
      Distinguishing Complex PTSD from Borderline Personality Disorder among individuals with a history of sexual trauma; a latent class analysis.
      ]. Complex trauma can influence the view of the self and others, and affects relationships and interactions with health care services, as well as help-seeking behaviour [
      • Fava N.M.
      • Simon V.A.
      • Smith E.
      • et al.
      Perceptions of general and parenting-specific posttraumatic change among postpartum mothers with histories of childhood maltreatment.
      ,
      • Cloitre M.
      • Hyland P.
      • Bisson J.I.
      • et al.
      ICD-11 posttraumatic stress disorder and complex posttraumatic stress disorder in the United States: a population-based study.
      ,
      • McDonald J.
      “It’s fine; i’m fine”: considerations for trauma-informed healthcare practices.
      ].
      The perinatal period (pregnancy to two years post-birth) offers a unique life course opportunity to promote intergenerational healing from complex trauma, through enabling access to validating and supportive programs [
      • Chamberlain C.
      • Ralph N.
      • Hokke S.
      • et al.
      Healing The Past By Nurturing The Future: a qualitative systematic review and meta-synthesis of pregnancy, birth and early postpartum experiences and views of parents with a history of childhood maltreatment.
      ,
      • Ranjbar N.
      • Erb M.
      • Mohammad O.
      • Moreno F.A.
      Trauma-informed care and cultural humility in the mental health care of people from minoritized communities.
      ,
      • Vignato J.
      • Georges J.M.
      • Bush R.A.
      • Connelly C.D.
      Post‐traumatic stress disorder in the perinatal period: a concept analysis.
      ]. Strategies and programs that support parents to manage feelings of trauma-related distress, address challenges, and promote positive parent–child interactions, may mitigate the deleterious effects of past parental experiences of trauma [
      • Sexton M.B.
      • Bennett D.C.
      • Muzik M.
      • Rosenblum K.L.
      Resilience, recovery, and therapeutic interventions for peripartum women with histories of trauma.
      ,
      • Chamberlain C.
      • Gee G.
      • Harfield S.
      • et al.
      Parenting after a history of childhood maltreatment: a scoping review and map of evidence in the perinatal period.
      ]. Many existing parenting support programs do not recognise or address the ongoing impacts of colonisation and intergenerational trauma on Aboriginal and Torres Strait Islander parents’ health and wellbeing [
      • Kilcullen M.
      • Swinbourne A.
      • Cadet-James Y.
      Aboriginal and Torres Strait Islander health and wellbeing: social emotional wellbeing and strengths‐based psychology.
      ].
      A number of parenting support programs have been developed from Western understandings of parenting and are provided as generic public health solutions [
      • Ray L.
      • Outten B.
      • Andrews P.
      • Gottlieb K.
      Disrupting the intergenerational transmission of trauma among Alaska Native People: a conceptual model for the family wellness warriors initiative.
      ,
      • Dudgeon P.
      • Scrine C.
      • Cox A.
      • Walker R.
      Facilitating empowerment and self-determination through participatory action research: findings from the National Empowerment Project.
      ]. However, Aboriginal and Torres Strait Islander, and indeed other First Nations populations have rich understandings of childrearing developed over millenia and specific needs for cultural safety, due to the legacies of colonisation [
      • Gee G.
      • Lesniowska R.
      • Santhanam-Martin R.
      • Chamberlain C.
      Breaking the cycle of trauma-Koori parenting what works for us.
      ,
      • Choate P.W.
      • CrazyBull B.
      • Lindstrom D.
      • Lindstrom G.
      Where do we go from here?: ongoing colonialism from Attachment Theory.
      ]. Support programs for Aboriginal and Torres Strait Islander parents require strengths-based strategies that focus on the presence of resilience and protective factors to reinforce the cultural, social, and emotional well-being of individuals, families and the community [
      • Dudgeon P.
      • Scrine C.
      • Cox A.
      • Walker R.
      Facilitating empowerment and self-determination through participatory action research: findings from the National Empowerment Project.
      ,
      • Farnbach S.
      • Gee G.
      • Eades A.-M.
      • et al.
      ‘We’re here to listen and help them as well’: a qualitative study of staff and Indigenous patient perceptions about participating in social and emotional wellbeing research at primary healthcare services.
      ].
      The aims of the broader, Healing the Past by Nurturing the Future (HPNF) study, include identifing culturally appropriate and feasible support strategies for Aboriginal and Torres Strait Islander parents who may be experiencing complex trauma. This paper describes the endorsement and refinement of a proposed set of parenting goals and support strategies for Aboriginal and Torres Strait Islander parents, presented and discussed at a participative stakeholder workshop.

      2. Method

      Commencing in 2018, this study sits within a wider program of Australian research, which seeks to develop an empowering framework for program design through ‘listening to parents’ and community stakeholders’ voices’. The HPNF team have worked with communities to build an evidence-base and generate new culturally responsive processes and effective support strategies for Aboriginal and Torres Strait Islander parents impacted by complex trauma in the perinatal period [
      • Chamberlain C.
      • Gee G.
      • Brown S.J.
      • et al.
      Healing the Past by Nurturing the Future—co-designing perinatal strategies for Aboriginal and Torres Strait Islander parents experiencing complex trauma: framework and protocol for a community-based participatory action research study.
      ].
      The HPNF project has been informed by Aboriginal and Torres Strait Islander research methodologies which include a commitment to decolonising research processes [
      • Dudgeon P.
      • Bray A.
      • Darlaston-Jones D.
      • et al.
      Aboriginal Participatory Action Research: an Indigenous Research Methodology Strengthening Decolonisation and Social and Emotional Wellbeing.
      ], and utilises an innovative co-design process [
      • Chamberlain C.
      • Gee G.
      • Brown S.J.
      • et al.
      Healing the Past by Nurturing the Future—co-designing perinatal strategies for Aboriginal and Torres Strait Islander parents experiencing complex trauma: framework and protocol for a community-based participatory action research study.
      ]. The broader study is described in detail elsewhere [
      • Chamberlain C.
      • Gee G.
      • Harfield S.
      • et al.
      Parenting after a history of childhood maltreatment: a scoping review and map of evidence in the perinatal period.
      ]. Briefly, the HPNF project uses both an Intervention Mapping framework [
      • Bartholomew-Eldredge L.
      Chapter 1: overview of intervention mapping.
      ] and a Community-based Participatory Action Research (CBPAR) approach [
      • Dudgeon P.
      • Bray A.
      • Darlaston-Jones D.
      • et al.
      Aboriginal Participatory Action Research: an Indigenous Research Methodology Strengthening Decolonisation and Social and Emotional Wellbeing.
      ]. We use the term ‘stakeholders’ to describe key groups with expertise, knowledge, and lived experience. This includes community members, Elders, grandparents, parents, counsellors, and service providers (Aboriginal and non-Aboriginal). The workshop discussed in this paper sought reciprocity in Aboriginal and Torres Strait Islander knowledge production [
      • Dudgeon P.
      • Bray A.
      • Darlaston-Jones D.
      • et al.
      Aboriginal Participatory Action Research: an Indigenous Research Methodology Strengthening Decolonisation and Social and Emotional Wellbeing.
      ] by returning to stakeholders to share the evidence HPNF had generated to date through the co-design process.

      2.1 Intervention mapping framework

      An intervention mapping framework is a planning approach which considers theory, research, and stakeholder views. HPNF uses intervention mapping to incorporate participatory methods to ensure that intervention development, implementation and evaluation are congruent with the needs of the focus population and the intervention context [
      • Chamberlain C.
      • Gee G.
      • Gartland D.
      • et al.
      Community perspectives of complex trauma assessment for Aboriginal parents: ‘its important, but how these discussions are held is critical’.
      ,
      • Bartholomew-Eldredge L.
      Chapter 1: overview of intervention mapping.
      ,
      • Fernandez M.E.
      • Ruiter R.A.C.
      • Markham C.M.
      • Kok G.
      Intervention mapping: theory- and evidence-based health promotion program planning: perspective and examples.
      ]. It is rigorous and systematic in detailing the decision-making at each step and emphasises the iterative and cumulative nature of the research [
      • Bartholomew-Eldredge L.
      Chapter 1: overview of intervention mapping.
      ,
      • Fernandez M.E.
      • Ruiter R.A.C.
      • Markham C.M.
      • Kok G.
      Intervention mapping: theory- and evidence-based health promotion program planning: perspective and examples.
      ]. Evidence suggests that public health and health promotion interventions developed from this approach are more effective due to the combination of theoretical and empirical evidence and stakeholder experiences [
      • Fernandez M.E.
      • Ruiter R.A.C.
      • Markham C.M.
      • Kok G.
      Intervention mapping: theory- and evidence-based health promotion program planning: perspective and examples.
      ].

      2.2 Community-based participatory action research (CBPAR)

      Participatory approaches are critical in First Nations research and was used in the current study to ensure Aboriginal and Torres Strait Islander voices and worldviews were privileged [
      • Chamberlain C.
      • Gee G.
      • Gartland D.
      • et al.
      Community perspectives of complex trauma assessment for Aboriginal parents: ‘its important, but how these discussions are held is critical’.
      ]. In the context of HPNF, the CBPAR approach aims to reduce the impact of power imbalances often inherent in research (i.e. between researcher and those being ‘researched’) and create safe, respectful, responsible, high quality and relevant research of benefit to the community [
      • NHMRC
      Ethical Conduct in Research with Aboriginal and Torres Strait Islander Peoples and Communities: Guidelines for Researchers and Stakeholders.
      ,
      • Tremblay M.-C.
      • Martin D.H.
      • McComber A.M.
      • McGregor A.
      • Macaulay A.C.
      Understanding community-based participatory research through a social movement framework: a case study of the Kahnawake schools diabetes prevention project.
      ]. It emphasises community control of the research (particularly data ownership) and involves collective, reflective, and systematic inquiry to increase use of findings, contribute to positive outcomes and mobilise social action and change [
      • NHMRC
      Ethical Conduct in Research with Aboriginal and Torres Strait Islander Peoples and Communities: Guidelines for Researchers and Stakeholders.
      ,
      • Tremblay M.-C.
      • Martin D.H.
      • McComber A.M.
      • McGregor A.
      • Macaulay A.C.
      Understanding community-based participatory research through a social movement framework: a case study of the Kahnawake schools diabetes prevention project.
      ]. The HPNF Project utilises embedded, iterative action research cycles within the intervention mapping framework and CBPAR approach. The action research mechanisms of ‘plan, act, observe, reflect’ incorporate the mixed methods research activities of evidence reviews, and participatory approaches of parent and service provider discussion groups, and stakeholder workshops. The project framework, incorporating intervention mapping and participatory research cycles, is depicted in Fig. 1.

      2.3 HPNF conceptual framework

      Data collected over 2018 and 2019 informed the study conceptual framework comprising four domains [author(s)]:
      • Awareness of the impact of trauma on parents or ‘trauma-informed’ perinatal care to minimise risks of triggering and compounding trauma responses.
      • Safe recognition of parents who may benefit from assessment and support, with processes to reduce risk of harm.
      • Assessment of complex trauma to accurately identify parents experiencing distress.
      • Support for parents to heal, including psychological, emotional, social, cultural and physical strategies.

      2.4 Parent support goals

      The parent support goals (see Fig. 2 and Supplementary File 1) were developed from past HPNF project initiatives. This involved qualitative, face-to-face yarning, workshops and related activities with members of several Aboriginal communities across Australia, in addition to qualitative evidence from two published reviews completed by the HPNF project team [
      • Chamberlain C.
      • Gee G.
      • Harfield S.
      • et al.
      Parenting after a history of childhood maltreatment: a scoping review and map of evidence in the perinatal period.
      ][
      • Chamberlain C.
      • Ralph N.
      • Hokke S.
      • et al.
      Healing The Past By Nurturing The Future: a qualitative systematic review and meta-synthesis of pregnancy, birth and early postpartum experiences and views of parents with a history of childhood maltreatment.
      ]. The eight parent goals and sixty support strategies were identified, extracted and grouped by three co-authors (two Aboriginal [YC/CC] researchers, one non-Aboriginal [CR]). The 60 support strategies are referred to in this paper as ‘examples’ of strategies used to achieve these eight goals, recognising this is an emerging area and the examples provided are not exhaustive.
      Fig. 2
      Fig. 2Flowchart describing the primary sources of evidence.

      2.5 Ethics

      The study had ethics approval from St Vincent’s Hospital Melbourne Human Research Ethics Committee (HREC, App. No. 50428, 023/19). . All participants provided written informed consent prior to participating in the workshop.

      2.6 Workshop

      2.6.1 Workshop: setting

      The workshop was held on the traditional lands of the Wurundjeri people of the Kulin Nation (Victoria, Australia) in November 2019. It was conducted at the Aborigines Advancement League, a historically and culturally important site located in the northern suburbs of Melbourne. The Aborigines Advancement League was formed in 1957 during the earliest Aboriginal rights movement, and established by William Cooper with Gordon Bryant, Doris Blackburn, and Pastor Douglas Nichols. The venue choice was an important part of creating a safe space for workshop participants, as discussed in previous publications [
      • Chamberlain C.
      • Gee G.
      • Brown S.J.
      • et al.
      Healing the Past by Nurturing the Future—co-designing perinatal strategies for Aboriginal and Torres Strait Islander parents experiencing complex trauma: framework and protocol for a community-based participatory action research study.
      ,
      • Clark Y.
      • Gee G.
      • Ralph N.
      • et al.
      The Healing the Past by Nurturing the Future: cultural and emotional safety framework.
      ].

      2.6.2 Workshop: stakeholder recruitment

      Stakeholders were invited to participate in the workshop via an electronic flyer and project newsletter distributed to the HPNF email list. This included a diverse group of professionals, parents, and community members with an interest in Indigenous perinatal and maternal health and wellbeing. Stakeholders were asked to click on a weblink to register their interest and provide brief registration details. Participation was voluntary and no payments were offered but travel and accommodation support was available on request.

      2.6.3 Workshop: structure and materials

      We facilitated a the three-hour session called: ‘Listening to parents’ voices’ to present to stakeholders the primary research evidence (see Fig. 2 and Supplementary File 1) gathered by the HPNF team that focused on parent support. A draft summary of the primary evidence was sent to stakeholders prior to the workshop for validation and an opportunity for further comment. The eight goals presented for discussion were:
      • 1
        Building resilience, strength, and empowerment
      • 2
        Compassionate care and support
      • 3
        Connections and reconnections
      • 4
        Parenting training education and skills
      • 5
        Practical assistance and life skills
      • 6
        Self-care
      • 7
        Enable, develop, and access to supports
      • 8
        Healing and therapeutic approaches
      The example strategies associated within each goal formed the descriptors of (parent) support (see Supplementary File 1.b). The eight goals (and their corresponding strategies) were displayed on A1-sized posters (each allocated a specific colour). These posters were placed on the walls of the workshop venue, as eight ‘stations’. Examples of blank and completed posters pre- and post-stakeholder input can be seen in Supplementary File 2.a.
      Two HPNF project members at each poster station facilitated stakeholder engagement and discussion, and took notes. Workshop attendees were encouraged to visit each poster station and asked to comment on practical examples and provide further suggestions for each goal and their associated example strategies. Attendees were additionally invited to indicate agreement or disagreement and add further comments on specific strategies. Stakeholder agreement/disagreement was indicated by placing a coloured dot against each strategy: (i) green – “I support the strategy”; (ii) orange – “I am unsure about this strategy”, and (iii) red – “I do not support this strategy”. Poster space was also available for other written comments and suggestions.

      2.6.4 Workshop: analysis

      Workshop data were analysed both quantitatively and qualitatively. Firstly, the number of stakeholder endorsements on the goals and strategies were summed (quantitative) (see Graph 1 ). Secondly, a stepped process was undertaken to analyse stakeholders’ (qualitative) perspectives of the goals and strategies [
      • Green J.
      • Thorogood N.
      Qualitative Methods for Health Research.
      ]. Two authors (an Aboriginal [GG] and non-Aboriginal [CR] researcher) independently reviewed the data. The purpose of the analysis was to identify any potential factors that helped parents, organisations, or community stakeholders to facilitate or enact the example parenting strategies associated with each goal. These potential factors were independently coded by [GG] and [CR], then codes were compared to identify any common factors and incorporate any potential differences. [GG] and [CR] then deliberated and aligned coding and came to agreement on groupings of core factors as enabling elements.
      Graph 1
      Graph 1Stakeholder overall endorsement for parent support goals.

      2.7 Findings

      Of the 71 stakeholders who registered, 54 attended the workshop (including 17 investigators and project staff). Non-project stakeholders (n = 37) came from the Australian jurisdictions of Tasmania, Northern Territory, South Australia, Victoria, New South Wales, and Queensland. We intentionally invited a majority (57%) of Aboriginal and/or Torres Strait Islander stakeholders to foster safety and privilege Aboriginal voices as the ‘norm’ rather than the minority. Aboriginal stakeholders represented 24 different Aboriginal language and family groups. Table 1 describes stakeholder characteristics.
      Table 1Stakeholder characteristics (N = 37).
      Stakeholder characteristicsn%
      Aboriginal/Torres Strait Islander2157
      Age-range (years)
       18–2438
       25–2925
       30–39719
       40–642259
       65 plus25
       Declined13
      Gender
       Male25
       Female3595
      Participated in a previous HPNF Workshop2568
      Role (multiple roles could apply)
       Partner organisation and/or peers1335
       Service providers e.g., Counsellors / Psychologists822
       Community member / Elder / Grandparent / Parent1130
       Student25
       Other38

      2.8 Endorsement of goals and example support strategies

      Stakeholders strongly supported all eight goals and associated strategies. There was consensus from stakeholders that parents need a broad range of support strategies across the eight goals, to accommodate diverse needs (e.g., geographical location, age, gender diversity) and parents’ stage of recovery. Summing the results for the example strategies under each goal showed that Goal 5. Practical assistance and life skills received the highest number (n = 162) of green dots (I support this strategy) followed by Goal 4. Parent training, education and skills (n = 107 green dots). Overall results for each goal are provided in Graph 1 .
      The example strategy with the most (green dots) endorsements was Assistance to reduce drug or alcohol use etc., with 21 green dots (goal 5, strategy 8). Next, all with 20 green dots were: Housing support (goal 5, strategy 3), Supporting or promoting exercise and, Establishing healthy boundaries and balance (e.g., learning to say ‘no’), (goal 6, example strategies 3 and 4).
      Single red dots (I do not support this strategy) were received for Housing support; Employment opportunities (Goal 5, example strategies 3 and 6), and Promoting time-out and ‘self-care’ (Goal 6, example strategy 1). Comments indicated non-agreement was due to the factor of ‘Timing’, i.e. parents cannot undertake these strategies without other preceding elements first occuring. (see Supplementary File 1.b for results for each individual strategy).

      2.9 Factors that help facilitate or enact the example strategies

      Four core factors were identified that help facilitate or enact strategies to support parents’ healing from complex trauma: Culture (cultural traditions, practices and strengths), Relationality (family, individual, community and services), Safety (frameworks, choice and control) and Timing (the right time socio-emotionally and stage of parenting). These factors are proposed as integral enablers to achieving parent goals, supported through the example strategies. These results formed from stakeholder perspectives are depicted in Fig. 3.
      Fig. 3
      Fig. 3Core factors that help facilitate support for parents to heal from complex trauma.
      Evidence supporting the four factors that facilitate support for parents to heal from complex trauma are described against each of the eight goals in text below. Additional feedback material is provided in Supplementary File 2.b

      2.9.1 Goal 1. Building resilience, strength, and empowerment (seven example strategies)

      • Bringing community together:
      • o
        Such as establishing community hubs (as a space to ‘bring in lawyers to answer questions and build capacity around women’s rights’).
      • o
        Valuing and prioritising community parenting (‘need people from community talking, sharing stories around’, examples given of, ‘Aunties, Deadly Nannas’).
      • Drawing on culture:
      • o
        Such as incorporating culture into ‘ways of working’, for example using a ‘bicultural model’ (Aboriginal and non-Aboriginal workers together)
      • o
        Use of cultural practices, such as, ‘holding cultural days, rites of passage, Belly casting, teaching kids to sing in language, traditional dance’.

      2.9.2 Goal 2. Compassionate care and support (seven example strategies)

      • Awareness of cultural safety frameworks:
      • o
        Use of trauma-informed care, which was expanded to include ‘culturally informed care’ and ‘trauma-integrated healing’.
      • o
        Cultural understandings of trauma, linking elements included, “cultural awareness” (‘staff orientation, cultural empathy, cultural mentorship’), “parent safety” (‘space aligns to the community, clothing, singing, cultural jigsaw, book writing’) and “continuity of care” (‘disconnected history, belonging, who’s your mob, sorry business opportunities’).
      • Relationships and partnerships:
      • o
        Understanding boundaries and confidentiality, for example partnerships (‘between community and organisations, two sides, care providers and parents coming forward’), including “whole of family” (requires cultural safety and compassion in care’), “cultural conversations” (‘conversations must be tailored and mindful’) and “worker power” versus empowerment (‘beware of dependency’).

      2.9.3 Goal 3. Connections and reconnections (six example strategies)

      • Cultural practices and activities:
      • o
        Context awareness for “cultural specificity” (‘different nation to nation, so specific for each community, cultural connections need to be driven by the community’). Examples included, ‘learning lullabies in language, yarning mat, traditional healers, bush medicine, smoking ceremony’.
      • Recognising healthy versus unhealthy connections:
      • o
        Discernment is needed between positive and harmful connections. Examples here were: ‘what does connection mean? - depends if relationship is healthy, beware of who you are learning from, understanding Indigenous’ and, ‘non-Indigenous aspects of support’.

      2.9.4 Goal 4. Parenting training education and skills (seven example strategies)

      • Recognising windows of opportunity when the timing is right alongside learning processes and their timing:
      • o
        Understanding the environment and awareness of opportunities, for example, community parenting [referring to community roles and responsibilities in parenting], work with dads, the transition period, healthy strong carer and child relationship (‘important time to work with the activation period of the attachment system’) understanding parent stress.
      • Coming to shared understandings of safety:
      • o
        Recognising carer/parenting relationships in cultural contexts for example, ‘Welcome to country ceremony, community parenting’. Linking elements involved - roles, safety, and choice, for example, ‘enabling parents to make their own choice -support them to create the safe environment’.

      2.9.5 Goal 5. Practical assistance and life skills (nine example strategies)

      • Prioritising and recognising individual needs:
      • o
        Identifying ‘staging of support’ for example ‘housing before employment’ and that it is very ‘person to person’ and also, ‘need culturally appropriate practical support at all times’ within ‘community organisations to maintain engagement’.
      • Timing and readiness:
      • o
        Understanding readiness and to ‘not set up to fail’ but build capacity and ‘they need to be ready for recovery’, and the person (parent/carer) needs to have the support and ‘capacity to maintain’ the gains.

      2.9.6 Goal 6. Self-care (four example strategies)

      • Recognising and redefining what is self-care:
      • o
        Recognising self-care ‘may need to be taught’, there is a difference between self-care (‘nurturing’) and time-out and, there will be different needs for different people and for ‘different community groups’.
      • o
        Redefining self-care to include ‘community care’ and ‘organisational care’ in addition to self-care.
      • Need for role models to learn self-care:
      • o
        Importance of support to value priorities in understanding not ‘feeling guilty about saying no, not blaming yourself’ (for example, ‘getting away when needing to’) but also ‘learning to say yes to self-care’.

      2.9.7 Goal 7. Enable, develop, and access to supports (nine example strategies)

      • Recognising healthy support:
      • o
        Recognising healthy support versus harmful support, need for ‘healthy social support’ (for example, some social networks and peer groups may be damaging), also identified was that ‘co-dependency needs to be avoided’, focus on different types of relationships which can be positive or negative and consider will the relationship heal or ‘further traumatise’.
      • Offering diversity of support:
      • o
        A need to offer diverse support accessible for example to, men, dads, parent groups, children, or community.

      2.9.8 Goal 8. Healing and therapeutic approaches (eleven example strategies)

      • Acknowledging healing is a journey:
      • o
        Being respectful of the healing journey, the time (‘you need more than time’) and the (‘culturally appropriate’) environment for healing.
      • Consideration of community and cultural fit:
      • o
        Understanding the need for trust, consistency, and that ‘restoration happens in community’ with ‘community parenting’ needed to help learn about trauma.

      3. Discussion

      This paper describes a rigorous action-based research approach to co-design culturally appropriate support strategies for Aboriginal and Torres Strait Islander parents and carers. Four core factors that help facilitate or enact the strategies that support parents to heal from complex trauma were identified: Culture, Relationality, Safety, and Timing. These core factors are important from a parenting perspective because simply identifying parenting strategies does not mean they will be accessible and utilised by parents.
      Based on analysis of stakeholder feedback and observations on the parenting goals and strategies presented in the workshop, it became clear that considerations around culture, relationality, safety, and timing (for service provision, for example) could help parents to utilise some of the example strategies and goals. For example, in order to facilitate ‘Practical assistance and life skills’ (goal 5) and associated strategies, it was important for organisations to consider ‘timing’ of introducing support, and the need to prioritise specific supports – otherwise there is a risk that the parent is not ready or able to access supports offered or to learn a particular skill. Another example is ‘Self-care’ parenting support goal 6, analysis revealed that it is important not to assume that parents will readily identify self-care strategies, and that role modelling is one important consideration, as is extending self-care considerations to include a ‘community care lens’, as the enabling factor of ‘relationalty’ highlights.
      Reflecting on the extant literature, Culture (cultural traditions, practices and strengths) enhances the effectiveness of programs for Aboriginal and Torres Strait Islander parents and carers and improves early childhood development [
      • McCalman J.
      • Heyeres M.
      • Campbell S.
      • et al.
      Family-centred interventions by primary healthcare services for Indigenous early childhood wellbeing in Australia, Canada, New Zealand and the United States: a systematic scoping review.
      ]. Prioritising culture within parent support strategies and recognising the impact of history and intergenerational trauma is a mechanism to disrupt further trauma transmission across generations and promote intergenerational healing [
      • Ray L.
      • Outten B.
      • Andrews P.
      • Gottlieb K.
      Disrupting the intergenerational transmission of trauma among Alaska Native People: a conceptual model for the family wellness warriors initiative.
      ,
      • Murrup‐Stewart C.
      • Searle A.K.
      • Jobson L.
      • Adams K.
      Aboriginal perceptions of social and emotional wellbeing programs: a systematic review of literature assessing social and emotional wellbeing programs for Aboriginal and Torres Strait Islander Australians perspectives.
      ]. Potentially traumatic experiences such as removal from family and loss of culture affects not just those who experience the event, but also their descendants [
      • Gee G.
      • Lesniowska R.
      • Santhanam-Martin R.
      • Chamberlain C.
      Breaking the cycle of trauma-Koori parenting what works for us.
      ,
      • Atkinson J.
      Lifting the Blankets: the Transgenerational Effects of Trauma in Indigenous Australia [PhD].
      ]. Cultural security for women in pregnancy and birth must be established along with trust in care relationships [
      • Chamberlain C.
      • Gee G.
      • Gartland D.
      • et al.
      Community perspectives of complex trauma assessment for Aboriginal parents: ‘its important, but how these discussions are held is critical’.
      ,
      • Marriott R.
      • Reibel T.
      • Coffin J.
      • et al.
      Wongi mi bardup (doing it our way): methodologies promoting Aboriginal knowledges and cultural practices for Birthing on Noongar Boodjar.
      ]. Birthing on Country is one such example of a model of care which has cultural significance for connection to ancestors and family and is important for cultural identity, cultural security and safety [
      • Kildea S.
      • Hickey S.
      • Barclay L.
      • et al.
      Implementing birthing on country services for Aboriginal and Torres Strait Islander families: RISE framework.
      ,
      • Marriott R.
      • Reibel T.
      • Coffin J.
      • et al.
      “Our culture, how it is to be us” — listening to Aboriginal women about on Country urban birthing.
      ]. ‘Culture’ as enabling the goals and example strategies in our study was specific to promoting strengths and resilience through Culture. This builds on previous findings by Atkinson in relation to the practices of deep traditional listening to support parents [
      • Atkinson J.
      Lifting the Blankets: the Transgenerational Effects of Trauma in Indigenous Australia [PhD].
      ,
      • Atkinson J.
      Trauma Trails, Recreating Song Lines: the Transgenerational Effects of Trauma in Indigenous Australia.
      ].
      The relationality enabling factors (family, individual, community, and services) were equally strength-based, and acknowledge Aboriginal and Torres Strait Islander (parent and child) identity [
      • Kilcullen M.
      • Swinbourne A.
      • Cadet-James Y.
      Aboriginal and Torres Strait Islander health and wellbeing: social emotional wellbeing and strengths‐based psychology.
      ,
      • Marriott R.
      • Reibel T.
      • Coffin J.
      • et al.
      Wongi mi bardup (doing it our way): methodologies promoting Aboriginal knowledges and cultural practices for Birthing on Noongar Boodjar.
      ]. These findings are similar to those found by Gatwiri et al. where relational methods in health care settings were identified as key decolonising factors which can improve access (policy, practice and everyday service interactions) for Australian First Nations People across the healthcare system [
      • Gatwiri K.
      • Rotumah D.
      • Rix E.
      Black lives matter in healthcare: racism and implications for health inequity among Aboriginal and Torres Strait Islander Peoples in Australia.
      ]. Our study adds to these findings; stakeholders highlighted community parenting as a strong relational element and the need to increase understanding and recognition of the importance of ‘sense of community’ for Aboriginal and Torrs Strait Islander people.
      Community parenting is parenting collectively or between families within a community. Ungunmerr-Baumann writes about community and identity as all persons matter and all persons belong in an Aboriginal community [
      • Ungunmerr-Baumann M.-R.
      To be listened to in her teaching: Dadirri: inner deep listening and quiet still awareness.
      ]. Hence, community and kinship networks need to be recognised for the healthy developmental of Aboriginal and Torres Strait Islander children and their identity [
      • Gee G.
      • Lesniowska R.
      • Santhanam-Martin R.
      • Chamberlain C.
      Breaking the cycle of trauma-Koori parenting what works for us.
      ]. Our findings also added the relational aspects with services as important. Stakeholders noted that relationships with services could be an enabling factor. An example is the use of bi-cultural workforce models which help to prioritise the Aboriginal and Torres Stait Islander voice and help to foster respectful relationships and communication between non-Aboriginal workers and care services.
      Safety (frameworks, choice and control) invests in the strength and resilience of parents. Lack of cultural safety is a barrier for Aboriginal and Torres Strait Islander peoples to access services [
      • Gatwiri K.
      • Rotumah D.
      • Rix E.
      Black lives matter in healthcare: racism and implications for health inequity among Aboriginal and Torres Strait Islander Peoples in Australia.
      ,
      • Murrup‐Stewart C.
      • Searle A.K.
      • Jobson L.
      • Adams K.
      Aboriginal perceptions of social and emotional wellbeing programs: a systematic review of literature assessing social and emotional wellbeing programs for Aboriginal and Torres Strait Islander Australians perspectives.
      ]. Stakeholders at our workshop emphasised the need for individualised and context-specific parent support and observed that current programs were mainly adapted models and not ‘culturally attuned’ reducing feelings of safety for program participants. Safety is essential in the context of trauma; an individualised cultural environment along with the language of safety must be congruent to create safe spaces to listen to and to hear parents [
      • Clark Y.
      • Gee G.
      • Ralph N.
      • et al.
      The Healing the Past by Nurturing the Future: cultural and emotional safety framework.
      ]. Previous research similarly indicates that community-based or community-controlled primary health care programs are critical to empower choice and control for Aboriginal and Torres Strait Islander peoples [
      • Gatwiri K.
      • Rotumah D.
      • Rix E.
      Black lives matter in healthcare: racism and implications for health inequity among Aboriginal and Torres Strait Islander Peoples in Australia.
      ,
      • McCalman J.
      • Heyeres M.
      • Campbell S.
      • et al.
      Family-centred interventions by primary healthcare services for Indigenous early childhood wellbeing in Australia, Canada, New Zealand and the United States: a systematic scoping review.
      ,
      • Murrup‐Stewart C.
      • Searle A.K.
      • Jobson L.
      • Adams K.
      Aboriginal perceptions of social and emotional wellbeing programs: a systematic review of literature assessing social and emotional wellbeing programs for Aboriginal and Torres Strait Islander Australians perspectives.
      ].
      Workshop stakeholders additionally reflected on their experiences of safety in the presence of Aboriginal Community Controlled Health Organisations (ACCHOs) whereby ‘development of safe positive relationships between parents and workers is really strengthened, lateral violence decreases, young families get that modelling’. Our study also contributes to findings that important program characteristics to increase safety include staffing, use of language, and context specific cultural responses and behaviours [
      • Murrup‐Stewart C.
      • Searle A.K.
      • Jobson L.
      • Adams K.
      Aboriginal perceptions of social and emotional wellbeing programs: a systematic review of literature assessing social and emotional wellbeing programs for Aboriginal and Torres Strait Islander Australians perspectives.
      ].
      Timing (the right time socio-emotionally and stage of parenting) of engaging with support strategies was also seen as an important enabling factor as the (program) ‘space needs to align with community and on parents’ level’. The perinatal period may be the first time since childhood that regular, frequent contact with health care providers occurs [
      • Chamberlain C.
      • Gee G.
      • Brown S.J.
      • et al.
      Healing the Past by Nurturing the Future—co-designing perinatal strategies for Aboriginal and Torres Strait Islander parents experiencing complex trauma: framework and protocol for a community-based participatory action research study.
      ,
      • Carlin E.
      • Atkinson D.
      • Marley J.V.
      Having a quiet word’: yarning with Aboriginal women in the Pilbara region of Western Australia about mental health and mental health screening during the perinatal period.
      ]. Parents also need to be at a stage where they can manage the difficult emotions of healing [
      • Gee G.
      • Lesniowska R.
      • Santhanam-Martin R.
      • Chamberlain C.
      Breaking the cycle of trauma-Koori parenting what works for us.
      ]. Timing can be essential in decision-making for parents, families, and communities as competing priorities can increase anxiety, stress and trauma responses [
      • Fitzgerald M.
      • London‐Johnson A.
      • Gallus K.L.
      Intergenerational transmission of trauma and family systems theory: an empirical investigation.
      ]. Therefore holistic, intergenerational strength-based perspectives need to consider parents’ physical, social, spiritual and emotional well-being needs alongside the history and impact of trauma [
      • Kilcullen M.
      • Swinbourne A.
      • Cadet-James Y.
      Aboriginal and Torres Strait Islander health and wellbeing: social emotional wellbeing and strengths‐based psychology.
      ]. Combined with access to support at the right time, increased motivation to seek support for change (due to becoming a parent), services acknowledging and recognising a parent experiencing complex trauma, the concept of timing as an enabling factor is critical to provide an opportunity to support positive (intergenerational) healing.

      3.1 Strengths and limitations

      A major strength is that this study was situated within a broader program of research HPNF that is Aboriginal-led, with a focus on co-design with key Aboriginal stakeholders. We recognise that the stakeholders represented at our workshop, although diverse, will not necessarily reflect the rich and varied experiences and perspectives of all Aboriginal and Torres Strait Islander peoples. Hence, the representativeness of stakeholders who attended our workshop may be limited. At the same time, Aboriginal and Torres Strait Islander communities are not homogenous groups but encompass diverse languages and practices. Each individual and community has unique traditions and parenting approaches and contextual sensitivy is an essential consideration.

      4. Conclusion

      This study identified Culture, Relationality, Safety, and Timing as essential elements to facilitate and/or enable the enactment of support startegies for Aboriginal and Torres Strait Islander parents. These enabling factors were framed as strengths-based and critical to aid healing for Aboriginal parents experiencing complex trauma. The eight goals and example strategies from the HPNF co-design process will be useful as a framework for parenting program design, as guidelines or as practice principles for implementation of models for context specific support for Aboriginal and Torres Strait Islander parents in the perinatal period experiencing complex trauma.
      Presenting our prior work on parents’ voices at the stakeholder workshop provided a valuable opportunity to deconstruct the parent support goals in group discussion and refine and validate these concepts. There was strong consensus on the need for a broad range of support strategies for parents experiencing trauma (i.e. not just psychological support). There is a need to now further develop practical resources for parents and to, implement, and evaluate these strategies in perinatal care to address cumulative and compounding cycles of intergenerational trauma.

      Conflict of interest

      The authors declare no conflict of interest.

      Ethical statement

      The study had ethics approval from St Vincent’s Hospital Melbourne Human Research Ethics Committee (HREC, App. No. 50428, 023/19). All participants provided written informed consent prior to participating in the research.

      Funding

      The Healing the Past by Nurturing the Future work is supported by the Lowitja Institute and a National Health and Medical Research Council (NHMRC) project grant [1141593]. The principal supervisor (CC) was supported by an NHMRC Career Development Fellowship (1088813). Other authors supported by NHMRC Fellowships, include (Early Career Fellowship 1161841), YC (Emerging Leader Fellowship1178590). Research staff at the Murdoch Children’s Research Institute are supported by the Victorian Government’s Operational Infrastructure Support Program. The first author (CR) is a PhD candidate with a scholarship funded by La Trobe University and an additional stipend from Healing the Past by Nurturing the Future Project.

      Author contributions

      Carol Reid: Data curation and formal analysis; Project administration; Resources; Original manuscript draft preparation, Writing, reviewing and editing (lead). Graham Gee: Data curation and formal analysis; Writing, reviewing and editing. Shannon Bennetts: Methodology; Writing, reviewing and editing. Yvonne Clark: Data curation; Methodology; Validation of data analysis. Reviewing and editing. Caroline Atkinson: Validation of data analysis; Reviewing and editing. Danielle Dyall: Validation of data analysis; Reviewing and editing. Jan Nicholson: Reviewing and editing. Catherine Chamberlain: Conceptualisation of the study (lead); Funding acquisition; Methodology; Validation of data analysis; Reviewing and editing. All authors revised the final manuscript. Catherine Chamberlain is the PhD Candidate’s (Carol Reid) principal supervisor.

      Data availability statement

      The raw data supporting the conclusions of this paper will be made available by the authors, on request.

      Acknowledgements

      This paper acknowledges the Aboriginal and Torres Strait Islander peoples as Australia’s First Peoples and the Traditional Owners and Custodians of the land.
      The study recognises the Healing the Past by Nurturing the Future (HPNF) Investigators and Co-design groups involved with the design and development of the HPNF conceptual framework. Members of the HPNF Investigators Group are: Dr Catherine Chamberlain, Dr Graham Gee, Dr Stephanie Brown, Dr Judy Atkinson, Dr Jan Nicholson, Deidre Gartland, Dr Helen Herrman, Karen Glover, Dr Yvonne Clark, Dr Fiona Mensah, Dr Caroline Atkinson, Shawana Andrews, Dr Sue Brennan, Dr Helen McLachlan, Tania Hirvonen, Dr Sue Campbell, Dr Naomi Ralph, Danielle Dyall.
      HPNF would like to thank everyone for their generosity and sharing of knowledge and expertise who participated in the co-design workshop.
      We also acknowledge our partner organisations for their oversight and leadership in this project including Victorian Aboriginal Community Controlled Health Organisation, Royal Women’s Hospital, Bouverie Family Healing Centre, Nunkuwarrin Yunti of South Australia Inc., Women’s and Children’s Health Network of South Australia, and the Central Australian Aboriginal Congress. We thank Dr Rhonda Marriott and Dr Jane Fisher for their ‘critical friendship’ to the project.

      Appendix A. Supplementary data

      References

        • Barlow J.
        • Coren E.
        The effectiveness of parenting programs: a review of Campbell reviews.
        Res. Soc. Work Pract. 2018; 28: 99-102
        • Pierron A.
        • Fond-Harmant L.
        • Laurent A.
        • Alla F.
        Supporting parenting to address social inequalities in health: a synthesis of systematic reviews.
        BMC Public Health. 2018; 18: 1471-2458
        • Chamberlain C.
        • Gee G.
        • Brown S.J.
        • et al.
        Healing the Past by Nurturing the Future—co-designing perinatal strategies for Aboriginal and Torres Strait Islander parents experiencing complex trauma: framework and protocol for a community-based participatory action research study.
        BMJ Open. 2019; 9e028397
        • Sexton M.B.
        • Bennett D.C.
        • Muzik M.
        • Rosenblum K.L.
        Resilience, recovery, and therapeutic interventions for peripartum women with histories of trauma.
        in: Muzik M. Rosenblum K. Motherhood in the Face of Trauma. Springer International Publishing, Cham2017: 115-129
        • Chamberlain C.
        • Gee G.
        • Harfield S.
        • et al.
        Parenting after a history of childhood maltreatment: a scoping review and map of evidence in the perinatal period.
        PLoS One. 2019; 14e0213460
        • Cromer L.D.
        • Gray M.E.
        • Vasquez L.
        • Freyd J.J.
        The relationship of acculturation to historical loss awareness, institutional betrayal, and the intergenerational transmission of trauma in the American Indian experience.
        J. Crosscult. Psychol. 2018; 49: 99-114
        • Gatwiri K.
        • Rotumah D.
        • Rix E.
        Black lives matter in healthcare: racism and implications for health inequity among Aboriginal and Torres Strait Islander Peoples in Australia.
        Int. J. Environ. Res. Public Health. 2021; 18: 4399
        • Chamberlain C.
        • Gee G.
        • Gartland D.
        • et al.
        Community perspectives of complex trauma assessment for Aboriginal parents: ‘its important, but how these discussions are held is critical’.
        Front. Psychol. 2020; 11
        • Fava N.M.
        • Simon V.A.
        • Smith E.
        • et al.
        Perceptions of general and parenting-specific posttraumatic change among postpartum mothers with histories of childhood maltreatment.
        Child Abuse Negl. 2016; 56: 20-29
        • Brewin C.R.
        • Cloitre M.
        • Hyland P.
        • et al.
        A review of current evidence regarding the ICD-11 proposals for diagnosing PTSD and complex PTSD.
        Clin. Psychol. Rev. 2017; 58: 1-15
        • Chamberlain C.
        • Ralph N.
        • Hokke S.
        • et al.
        Healing The Past By Nurturing The Future: a qualitative systematic review and meta-synthesis of pregnancy, birth and early postpartum experiences and views of parents with a history of childhood maltreatment.
        PLoS One. 2019; 14e0225441
        • Berthelot N.
        • Lemieux R.
        • Lacharité C.
        Development of a prenatal program for adults with personal histories of childhood abuse or neglect: a Delphi consensus consultation study.
        Health Promot. Chron. Dis. Prev. Can. Res. Policy Pract. 2018; 38: 393
        • Cloitre M.
        • Shevlin M.
        • Brewin C.R.
        • et al.
        The International Trauma Questionnaire: development of a self‐report measure of ICD‐11 PTSD and complex PTSD.
        Acta Psychiatr. Scand. 2018; 138: 536-546
        • Erickson N.
        • Julian M.
        • Muzik M.
        Perinatal depression, PTSD, and trauma: impact on mother–infant attachment and interventions to mitigate the transmission of risk.
        Int. Rev. Psychiatry. 2019; 31: 245-263
        • Frost R.
        • Hyland P.
        • Shevlin M.
        • Murphy J.
        Distinguishing Complex PTSD from Borderline Personality Disorder among individuals with a history of sexual trauma; a latent class analysis.
        Eur. J. Truama Dissociation. 2018; 4: 100080
        • Cloitre M.
        • Hyland P.
        • Bisson J.I.
        • et al.
        ICD-11 posttraumatic stress disorder and complex posttraumatic stress disorder in the United States: a population-based study.
        J. Trauma. Stress. 2019; 32: 833-842
        • McDonald J.
        “It’s fine; i’m fine”: considerations for trauma-informed healthcare practices.
        J. Aggress. Maltreat. Trauma. 2020; 29: 385-399
        • Ranjbar N.
        • Erb M.
        • Mohammad O.
        • Moreno F.A.
        Trauma-informed care and cultural humility in the mental health care of people from minoritized communities.
        Focus. 2020; 18: 8-15
        • Vignato J.
        • Georges J.M.
        • Bush R.A.
        • Connelly C.D.
        Post‐traumatic stress disorder in the perinatal period: a concept analysis.
        J. Clin. Nurs. 2017; 26: 3859-3868
        • Kilcullen M.
        • Swinbourne A.
        • Cadet-James Y.
        Aboriginal and Torres Strait Islander health and wellbeing: social emotional wellbeing and strengths‐based psychology.
        Clin. Psychol. 2018; 22: 16-26
        • Ray L.
        • Outten B.
        • Andrews P.
        • Gottlieb K.
        Disrupting the intergenerational transmission of trauma among Alaska Native People: a conceptual model for the family wellness warriors initiative.
        J. Health Dispar. Res. Pract. 2019; 12: 40-71
        • Dudgeon P.
        • Scrine C.
        • Cox A.
        • Walker R.
        Facilitating empowerment and self-determination through participatory action research: findings from the National Empowerment Project.
        Int. J. Qual. Methods. 2017; 16: 1-11
        • Gee G.
        • Lesniowska R.
        • Santhanam-Martin R.
        • Chamberlain C.
        Breaking the cycle of trauma-Koori parenting what works for us.
        First Peoples Child Fam. Rev. 2020; 15: 45-66
        • Choate P.W.
        • CrazyBull B.
        • Lindstrom D.
        • Lindstrom G.
        Where do we go from here?: ongoing colonialism from Attachment Theory.
        Aotearoa N. Z. Soc. Work. 2020; 32: 32-44
        • Farnbach S.
        • Gee G.
        • Eades A.-M.
        • et al.
        ‘We’re here to listen and help them as well’: a qualitative study of staff and Indigenous patient perceptions about participating in social and emotional wellbeing research at primary healthcare services.
        BMC Psychiatry. 2019; 19: 294
        • Dudgeon P.
        • Bray A.
        • Darlaston-Jones D.
        • et al.
        Aboriginal Participatory Action Research: an Indigenous Research Methodology Strengthening Decolonisation and Social and Emotional Wellbeing.
        Lowitja Institute, 2020
        • Bartholomew-Eldredge L.
        Chapter 1: overview of intervention mapping.
        in: Bartholomew-Eldredge L. Markham C. Ruiter R.A. Fernandez M.E. Kok G. G.P Planning Health Promotion Programs: an Intervention Mapping Approach. fourth ed. Jossey-Basss, Wiley, San Francisco, CA2016: 12-19
        • Fernandez M.E.
        • Ruiter R.A.C.
        • Markham C.M.
        • Kok G.
        Intervention mapping: theory- and evidence-based health promotion program planning: perspective and examples.
        Front. Public Health. 2019; 7: 209
        • NHMRC
        Ethical Conduct in Research with Aboriginal and Torres Strait Islander Peoples and Communities: Guidelines for Researchers and Stakeholders.
        National Health and Medical Research Council, 2018
        • Tremblay M.-C.
        • Martin D.H.
        • McComber A.M.
        • McGregor A.
        • Macaulay A.C.
        Understanding community-based participatory research through a social movement framework: a case study of the Kahnawake schools diabetes prevention project.
        BMC Public Health. 2018; 18: 487
        • Clark Y.
        • Gee G.
        • Ralph N.
        • et al.
        The Healing the Past by Nurturing the Future: cultural and emotional safety framework.
        J. Indigenous Wellbeing. 2020; 5: 38-57
        • Green J.
        • Thorogood N.
        Qualitative Methods for Health Research.
        Fourth ed. Sage, London2018
        • McCalman J.
        • Heyeres M.
        • Campbell S.
        • et al.
        Family-centred interventions by primary healthcare services for Indigenous early childhood wellbeing in Australia, Canada, New Zealand and the United States: a systematic scoping review.
        BMC Pregnancy Childbirth. 2017; 17: 71
        • Murrup‐Stewart C.
        • Searle A.K.
        • Jobson L.
        • Adams K.
        Aboriginal perceptions of social and emotional wellbeing programs: a systematic review of literature assessing social and emotional wellbeing programs for Aboriginal and Torres Strait Islander Australians perspectives.
        Aust. Psychol. 2018; 54: 171-186
        • Atkinson J.
        Lifting the Blankets: the Transgenerational Effects of Trauma in Indigenous Australia [PhD].
        Queensland University of Technology, 2001
        • Marriott R.
        • Reibel T.
        • Coffin J.
        • et al.
        Wongi mi bardup (doing it our way): methodologies promoting Aboriginal knowledges and cultural practices for Birthing on Noongar Boodjar.
        Int. J. Crit. Indigenous Stud. 2019; 12: 15-28
        • Kildea S.
        • Hickey S.
        • Barclay L.
        • et al.
        Implementing birthing on country services for Aboriginal and Torres Strait Islander families: RISE framework.
        Women Birth. 2019; 32: 466-475
        • Marriott R.
        • Reibel T.
        • Coffin J.
        • et al.
        “Our culture, how it is to be us” — listening to Aboriginal women about on Country urban birthing.
        Women Birth. 2019; 32: 391-403
        • Atkinson J.
        Trauma Trails, Recreating Song Lines: the Transgenerational Effects of Trauma in Indigenous Australia.
        Spinifex Press, 2002
        • Ungunmerr-Baumann M.-R.
        To be listened to in her teaching: Dadirri: inner deep listening and quiet still awareness.
        EarthSong J. Perspect. Ecol. Spirituality Educat. 2017; 3: 14-15
        • Carlin E.
        • Atkinson D.
        • Marley J.V.
        Having a quiet word’: yarning with Aboriginal women in the Pilbara region of Western Australia about mental health and mental health screening during the perinatal period.
        Int. J. Environ. Res. Public Health. 2019; 16: 4253
        • Fitzgerald M.
        • London‐Johnson A.
        • Gallus K.L.
        Intergenerational transmission of trauma and family systems theory: an empirical investigation.
        J. Fam. Ther. 2020; 42: 406-424