Gaawaadhi Gadudha: A stepped-wedge cluster randomised trial and evaluation of the effectiveness of an Aboriginal cultural health program

The trial program will be delivered by the Gamilaraay, Yuwaalaraay, and Yuin (Aboriginal) Senior Cultural Health Facilitators and Cultural Health Facilitators, with support from Assistant Cultural Health Facilitators in each region. Senior Cultural Health Facilitators are respected cultural knowledge holders from their respective regions, who are experienced in delivering cultural health support and care, including the provision of cultural camps on Country, teaching Aboriginal languages, transmission of cultural knowledges of plants, foods and medicines, and traditional healing modalities. Because the Senior Cultural Health Facilitators were involved in co-designing the trial program and implementation plan, training to deliver the program will not be necessary. However, a workshop with the principal coordinating investigator will be held prior to trial program commencement, to ensure the program delivery team are confident that the program’s ‘implementation plan’ is feasible and appropriate, and to clarify any potential issues before commencing. The Cultural Health Program will be delivered over a 2-month period to each cluster (total 4 clusters). The required contact time for participants is 112 hours which includes the following components: two yarning circle sessions at the beginning and end of the program (4 hours); five Gamilaraay (Northwestern region) or Yuin-Djirringanj (Far South Coast region) language sessions (2 hours per session, held fortnightly); one cultural medicine workshop (3 hours); one cultural foods gathering (3 hours); one cultural camp on-Country (4 days/96 hours). Details for each component are below. Attendance logs will be recorded by Cultural Health Facilitators at every program activity in order to asses adherence and fidelity. Component 1 – Yarning circle start: Program participants will attend one 2-hour yarning circle at the beginning of the program in the community settings of Tamworth (Northwestern region) or Wallaga Lake (Far South Coast region). A welcome and acknowledgement of Country, and a smoking ceremony will occur prior to the official start of the yarning circle. Yarning circles are a culturally safe and non-hierarchical way of sharing experiences that promote relationality and reciprocity. Yarning circles will be facilitated by a Senior Cultural Health Facilitator or Cultural Health Facilitator, and will be gender-separated to observe cultural norms. Yarning circles will provide an opportunity for participants to be acquainted collectively, and for Cultural Health Facilitators to provide further clarification and depth on the program. Following this, Cultural Health Facilitators will use a yarning circle guide to encourage participants to share information about their cultural journey and aspirations, their cultural health needs, challenges moving forward in life, and expectations for the program. Yarning circles will be audio recorded and transcribed. Component 2 – Language course: Program participants will attend five language sessions (2 hours per session) which will occur on a mostly fortnightly basis in the community settings of Tamworth (Northwestern region) or Wallaga Lake (Far South Coast region). Language sessions will be delivered by a Language Educator and a Senior Cultural Health Facilitator and aim to equip participants with basic Gamilaraay (Northwestern region), or Yuin-Djirringanj (Far South Coast region) language competency. Each session will emphasise the importance of language in cultural connection, practice and identity. Aboriginal language competency is strongly associated with strength and pride in cultural identity, both of which are protective factors to Social and Emotional Wellbeing (SEWB). Language sessions will not cover gender-sensitive topics, and therefore it is deemed culturally appropriate to deliver them to male and female participants together in the one group. The language course will be delivered using the Language Course Outline. A brief description of structure is included below: Session 1: Introduction, program expectations, alphabet and pronunciation, terminology, generic words, phrases, and sounds, basic greetings, learn how to introduce yourself, activities. Session 2: Session 1 recap, receiving work booklet, addressing family, verbs/nouns/adjectives, suffixes and conjunctions, game, common phrase activity Session 3: Session 2 recap, learning on Country and place names, weapons and tools, food names Session 4: Session 3 recap, body parts, mammals, birds, activity Session 5: Session 4 recap, walk and talk on Country, reptiles, insects, marine life, creative writing activity, reflection, discuss use of language beyond program. Component 3 – Cultural medicines workshop: Program participants will attend one traditional medicine workshop (3 hours) in the community settings of Tamworth (Northwestern region) or Wallaga Lake (Far South Coast region). The cultural medicines workshop will be delivered by a Cultural Health Facilitator and aim to equip participants with knowledge of at least three key Gamilaraay (Northwestern region), or Yuin-Djirringanj (Far South Coast region) plant-based or animal-based medicines. Participants will be shown the unprocessed medicine (e.g. plant leaves or bark) and be encouraged to learn to identify each using sensory learning (see, touch, smell). They will then be given the processed version (e.g. brewed plant tea) to try, and be provided with knowledge on what each medicine is used for. A yarning circle about the importance of cultural medicines will follow, giving participants an opportunity to ask questions. Cultural medicine knowledge and the ability to share this intergenerationally is strongly associated with a sense of healing and pride in identity, both of which are protective factors to SEWB. Cultural medicine workshop will not cover gender-sensitive topics, and therefore it is deemed culturally appropriate to be delivered to male and female participants together in the one group. Component 4 – Cultural foods gathering: Program participants will attend one cultural foods gathering (3 hours) in the community settings of Tamworth (Northwestern region) or Wallaga Lake (Far South Coast region). The cultural foods gathering will be delivered by a Cultural Health Facilitator and aim to equip participants with knowledge of at least three key Gamilaraay (Northwestern region), or Yuin-Djirringanj (Far South Coast region) plant-based or animal-based foods. Participants will be shown how to prepare and cook cultural foods and be given the opportunity to try them. Cultural Health Facilitators will share knowledges on the medicinal properties of cultural foods. A yarning circle about the importance of cultural foods will follow, giving participants an opportunity to ask questions. Cultural food knowledge and the ability to share this intergenerationally is strongly associated with a sense of healing and pride in identity, both of which are protective factors to SEWB. Cultural food gathering will not cover gender-sensitive topics, and therefore it is deemed culturally appropriate to be delivered to male and female participants together in the one group. Component 5 – Cultural camp on Country: Program participants will attend one cultural camp that will be held in a cultural landscape (e.g. a landscape minimally impacted by colonisation) ‘on-Country’ in each region, facilitated by two Cultural Health Facilitators who hold knowledge of that Country. In the Northwestern region, the cultural camp location will be held at Narran Lakes. In the Far South Coast region, the cultural camp will be held near Gulaga National Park. The cultural camp will run for 4 days, allowing 2 days for travel to the location and set up/pack down. The cultural camp will observe gender-separated cultural norms, having separate men’s and women’s camp sites within the one camp. All food, equipment and travel will be provided for program participants. Cultural camps delivered by cultural knowledge holders of that Country are evidenced to positively impact indicators of cultural health, support healing, and provide stress relief. They do so by offering sensory experiences in a ‘natural’ environment and facilitating the learning and sharing of cultural knowledges and language, as well as engagement in cultural practices.9,10 The cultural camp combines elements of all other program components and delivers them in a culturally-safe setting on-Country. Some camp activities will be gender-separated and some combined, observing cultural norms, with a focus on cultural knowledge transmission, connection to Country, and learning and engaging in cultural practices (such as weaving, woodwork, fire yarning). A brief agenda of the cultural camp is as follows: Day 1: Travel 1/2 day, set up, welcome & smoking ceremony, fire yarn Day 2: Morning - Breakfast; cultural site visit & traditional story; Afternoon - Lunch at camp; weaving (women), woodwork (men); Evening: Fire yarns Day 3: Morning - Breakfast; cultural site visit & traditional story; Afternoon - Lunch at camp; weaving (women), woodwork (men); Evening: Fire yarns Day 4: Morning - Reflections; smoking ceremony & thank you, travel home. Component 6 – Yarning circle finish: Program participants will attend one 2-hour yarning circle at the completion of all other program components. Yarning circles will be facilitated by a Cultural Health Facilitator, and will be gender-separated to observe cultural norms. Cultural Health Facilitators will use a yarning circle guide to prompt participants to share reflections of the program, and if and how it contributed to their sense of cultural health, healing and wellbeing, and how they might integrate their experiences and knowledge gained from the program into their daily lives. Yarning circles will be audio recorded and transcribed.