Victorian Aboriginal Early Years Health Framework: Literature Review

The Victorian Aboriginal Early Years Health Framework (the Framework), an initiative of the Victorian Department of Health, is a holistic strategy aimed at improving the health and wellbeing of Aboriginal and Torres Strait Islander children in their first 1000 days. Through an Aboriginal-led participation and design process, with regional consultations conducted across the state, the Framework is informed by a set of principles that recognise the unique cultural needs and experiences of Aboriginal children, families, and communities. This literature establishes and synthesises evidence-based strategies of best-practice in health strategies and initiatives for Indigenous peoples, both nationally and internationally. This review draws upon academic research, state and federal government legislation and initiatives, and national and international case studies that can inspire opportunities for the Framework’s success.

Principles

Recognising that Aboriginal and Torres Strait Islander communities have the right to make decisions about their own health and wellbeing, the design of the Framework is underpinned by the principle of self-determination. This is also reflected in this literature review, wherein the national and international examples demonstrate the critical importance of empowering Indigenous peoples in the planning, design, and implementation of health services and strategies.

Furthermore, this literature review posits the significance of Indigenous research, design, and evaluation methodologies in developing an evidence-base that underscores strategies targeting Aboriginal and Torres Strait Islander peoples. In turn, not only must the Framework itself be informed by self-determination, but where possible so should the collation of evidence and data.

The inception of the Framework and this literature review acknowledges that cultural identity is central to health and wellbeing and that services need to be culturally safe and responsive for Aboriginal and Torres Strait Islander peoples. In addition, in-line with the holistic ethos of the Framework, this literature review explores the significance of the social determinants of health and the underlying causes of inequitable health outcomes.

Areas of focus

This literature review explores the socio-political, academic, social, and health imperatives for the Framework.

It includes the Victorian Government’s commitment to the Closing the Gap National Agreement as well as Treaty. It considers the development of the Framework within a policy and legislation context including Victoria, other states, and the Commonwealth. This is further contextualised within the context of international imperatives and priorities, factoring objectives and prerogatives set out by the United Nations and World Health Organization. By exploring International Indigenous early years health models and strategies, the literature review aims to provide correlations of universal best practice for Indigenous peoples as a foundation for evaluating Australian-based examples.

In examining existing Aboriginal and Torres Strait Islander early years health strategies, initiatives, and programs, the literature review includes key services across the first 1000 days of a child’s life. Here the primary focus is on health services as opposed to early education.

Key Targets

The key targets of the Framework are guided by those set out by the Closing the Gap National Agreement and Implementation Plan. The effectiveness of the Framework, therefore, should initially be measured against these Outcomes and Targets. Yet, through the consultation process it is essential that local-level targets are also identified with communities, and these may inform the benchmarks and targets to measure the Framework against.

Monitoring and Evaluation

In line with Indigenous methodologies included in this review, it is suggested that the Victorian Department of Health include monitoring and evaluation tools that are Aboriginal-led and involve local communities. These tools may measure success against benchmarks outlined in the Closing the Gap National Agreement, and also, agreed locally determined benchmarks and measures.

Questions to use in consultations

Based on the literature review, some key questions emerge that can guide the consultations with both health service stakeholders and parents/carers:

1. What are the Aboriginal Early Years? - this is the essential question that will underpin the workshops and forums, and determine which services are perceived to be necessary to include within the Framework.
2. What are the main service delivery touchpoints Aboriginal and Torres Strait Islander clients experience in their journey? - this qualitative question will support the quantitative data collected as part of the stakeholder survey distributed prior to consultations, and broaden the evidence base for the Framework.
3. How would you describe the journey of Aboriginal and Torres Strait Islander clients across the various services and programs involved in early childhood health? - extending upon the previous question, this question provides an evaluative understanding of the experience of clients along their journey map. This also correlates to the literature that endorses service integration and coordination.
4. What are the key enablers to accessing adequate early years health care for Aboriginal and Torres Strait Islander clients during this journey? - it is important to understand what is already working in service delivery, and to maintain and extend from these enablers.
5. What are the key barriers to accessing adequate early years health care for Aboriginal and Torres Strait Islander clients during this journey? - equally, it is important to understand the current barriers, and thus the imperative, of a holistic Framework.
6. What are the key targets the Victorian Aboriginal Early Years Health Framework must reach in order to be successful? - whilst there are targets and objectives outlined in existing state-based and national documents, to truly reflect co-design principles, stakeholders must have input into how the Framework is evaluated.

Whilst this is not an exhaustive list of questions that may be used during consultations, it provides an evidence-based foundation to guide discussion.

Purpose of this literature review

Karabena Consulting is undertaking this Literature Review as part of the Aboriginal-led participation and design process to inform the development of the Framework. This document examines and synthesises case studies and evidence on Aboriginal-relevant, proven and evidence based antenatal, maternal child health and early parenting approaches, programs, services, and interventions. It draws upon State and National Aboriginal-specific contexts, International Indigenous contexts, and academic literature to identify proven successful evidence-based service models and client journey maps, and in so doing proposes recommendations and considerations the Framework.

Socio-political context

The Uluru Statement from the Heart calls for a framework of political, systemic, and structural action informed by Voice, Treaty, and Truth, with the ultimate aim for Aboriginal and Torres Strait Islander people ‘to be heard’ in the spirit of self-determination (First Nations National Constitutional Convention and Central Land Council 2017). Currently, within Victoria it is edifying to see the inception of these guiding principles as the First Peoples’ Assembly of Victoria prepares to negotiate Treaty with the Victorian Government, and the Yoorrook Justice Commission undertakes its commitment to truth-telling processes of Truth, Understanding, and Transformation (Yoorrook Justice Commission 2022). Furthermore, at the time of writing this literature review the Referendum to enshrine an Aboriginal and Torres Strait Islander Voice to Parliament provides further hope that the aspiration of the Uluru Statement from the Heart will be fulfilled. Underscored by the proposition of truth-telling and self-determination, both these State and National level initiatives lay a timely foundation for Aboriginal and Torres Strait Islander participation and representation in programs and initiatives affecting their peoples and communities. Therefore, the Victorian Aboriginal-led participation and design process in developing a holistic early years health Framework is pertinent and necessary - prioritising the experiences, voices, and perspectives of Aboriginal and Torres Strait Islander families and early years health workers is essential. Given the imminent Treaty negotiations in Victoria, the development of the Framework possesses the exciting opportunity to prepare the Treaty generation, those young people growing up in a context after a Victorian Treaty is signed and enacted.

Academic context: Indigenist research and evaluation methodologies

Whilst these socio-political examples reflect the need for Aboriginal and Torres Strait Islander participation and representation, academic literature into research and design methodologies related to Aboriginal and Torres Strait Islander programs and initiatives further reinforce the requirement for these principles in informing program design. Most health research involving Aboriginal and Torres Strait Islander people, up to this point, has been conducted by non-Indigenous people and has not been a positive experience (Biles et al. 2022). Engaging Aboriginal and Torres Strait Islander communities in the process of designing and evaluating programs that will affect them ‘is a key feature of effective evaluation, building trust and enhancing relevancy for communities and providing meaningful outcomes’ (Vine et al. 2023:1). Furthermore, engaging in a process underpinned by Indigenist research and evaluation methodologies, encompassing features such as reciprocity and co-design, creates a culturally safe process that empowers the communities and individuals. As Maher et al. posit, such a research and design process:

...promotes evaluation as inclusive, safe, respectful and ethically aligned with Aboriginal and Torres Strait Islander ways of knowing, being and doing. Further, Indigenist approaches support leadership capability of Aboriginal and Torres Strait Islander people and communities in evaluation. (Maher et al. 2021:2)

The Lowitja Institute also acknowledges the critical importance of Aboriginal and Torres Strait Islander-led evaluation of programs and services, underscoring their Tools for Culturally Safe Evaluation with relevant criteria (Lowitja Institute 2022). Modes of community engagement in the participation, evaluation, and design may be varied, and include ‘representation on governance groups, authorship, involvement in the evaluation processes and whole community consultation’ (Vine et al. 2023:8). Whilst evidence of successful community engagement in the evaluation and design of health services and programs is mixed, especially in terms of community consultation, the inherent obligation to do so remains, especially in keeping with The Declaration on the Rights of Indigenous people’s right to ‘maintain, control, protect and develop their cultural heritage’ (UN 2007).

Therefore, an Aboriginal-led participation and design process to inform the development of a holistic Framework is grounded in Indigenist academic research and evaluation methodology. An approach that is inclusive of community perspectives at a localised level will ensure that such a Framework considers the varied needs and aspirations of Aboriginal and Torres Strait Islander peoples across the State, but also accounts for the nuances that differ between various communities.

Commonwealth Closing the Gap Implementation Plan 2023

Getting the Framework right will establish strong foundations for redressing societal inequities that Aboriginal and Torres Strait Islander people experience at all stages of life and provide a vehicle for closing the current gap in key indicators of life outcomes compared to non-Indigenous Australians. As the authors of the Family Matters Report simply yet poignantly postulate, the ‘[early] years matter most to changing the storyline for our families’ (Liddle et al. 2021:4).

Against the Commonwealth Closing the Gap Implementation Plan 2023 (Commonwealth of Australia 2023) targets for outcomes directly related to Early Years Health, there are mixed results. Although targets for Outcomes 2 and 3 (Aboriginal and Torres Strait Islander children are born healthy and strong; Aboriginal and Torres Strait Islander children are engaged in high quality, culturally appropriate early childhood education in their early years) are on track, there is still scope for improvement. Unfortunately, the target for Outcome 4 (Aboriginal and Torres Strait Islander children thrive in their early years) is not on track, and has rather decreased since the collection of baseline data in 2018 (Commonwealth of Australia 2023).

Referring to these targets, current data and future priorities is an essential component in the process of developing a holistic Framework through identifying a baseline approach. Using these indicators and priority actions, key implications emerge including the need to further increase and integrate community controlled maternity services, and Aboriginal maternal and child health services (such as Koori Maternity Services (KMS)), to ensure a culturally safe and responsive experience for children and families not consistently evident in mainstream services. Furthermore, it is essential to explore strategies for Aboriginal and Torres Strait Islander people to have ongoing input into delivery services that are ideally community-controlled and community-led. Exploring localised recruitment and retention strategies will assist in increasing Aboriginal and Torres Strait Islander workforce participation and thus a more culturally safe and responsive service delivery. Finally, it is clear that access to First Nations playgroups and early childhood education strategies that are culturally responsive and community-led will increase a sense of connectedness, and in turn contribute to school readiness.

Ultimately, it is important to note that a holistic Framework must incorporate multiple streams of service delivery including clinical health, social health and education. Whilst children form the central aspirations of the Framework, it cannot discount the significant role of parents, caregivers, families, and the broader community in the social and emotional development of young people. This is further reinforced in the Family Matters Report that identifies the multitudinous structural drivers and service inadequacies that contribute to Aboriginal and Torres Strait Islander children encountering the child protection system. This includes inequities in services aimed at children and mothers, such as maternal and child health inequities and barriers to participation in early childhood education and care. However, it also examines the broader barriers such as socioeconomic disadvantage, poor access to safe and affordable housing, exposure to family violence, drug and alcohol misuse, mental ill-health, and inadequate government investment in family support services (Liddle et al. 2021). Adopting this wider lens when developing a holistic Framework will increase the likelihood of effective integration and coordination of a range of services that serve to support the aspirations of Aboriginal and Torres Strait Islander children, parents, families and communities.

National Aboriginal and Torres Strait Islander Early Childhood Strategy

From both a methodological approach and goal-determining lens, the National Aboriginal and Torres Strait Islander Early Childhood Strategy also carries implications that can inform the process of developing a holistic Framework. In particular, the methodological approach of drawing upon an ‘evidence base of “what works” for Aboriginal and Torres Strait Islander children from a culturally-informed and trauma-informed perspective’ (NIAA 2022:7) provides an exemplar of theoretical practice in designing programs and frameworks. Even further, though, the co-design and consultation process in developing the Strategy involved a broad consultation process that engaged Aboriginal and Torres Strait Islander stakeholders and people nationally. This included both virtual and ‘on the ground’ consultations through ACCOs that enabled widespread Aboriginal and Torres Strait Islander participation in determining what ‘needs to be done to better support Aboriginal and Torres Strait Islander children and families to thrive’ (NIAA 2022:7). Hence, a similar process of maximising input from Aboriginal service providers and peoples across the state in designing the holistic Framework reflects this widespread co-design methodology.

Further to the methodological considerations, the Strategy’s five goals arising from the co-design and consultation process signify a guiding foundation for the establishment of a Victorian-based Framework:

1. Aboriginal and Torres Strait Islander children are born healthy and remain strong: emphasising the need for the Framework to encompass accessible, consistent and culturally safe and responsive antenatal and maternal health services.
2. Aboriginal and Torres Strait Islander children are supported to thrive in their early years: emphasising the need for the Framework to encompass accessible, consistent, and culturally safe and responsive maternal child health, paediatric and playgroup/kindergarten services.
3. Aboriginal and Torres Strait Islander children are supported to establish and maintain strong connections to culture, Country and language: emphasising the need for the Framework to encompass cultural identity and connectedness within early education and health services.
4. Aboriginal and Torres Strait Islander children grow up in safe nurturing homes, supported by strong families and communities: emphasising the need for the Framework to encompass effective integration and coordination of parent coaching services, mothers/fathers groups, in addition to crisis services.
5. Aboriginal and Torres Strait Islander children, families and communities are active partners in building a better service system: emphasising the need for the Framework to prioritise the role of community-controlled and Aboriginal-led services, as well as scope for reciprocity and co-design strategies with families and communities.

Similarly to the priority actions in the Closing the Gap Implementation Plan 2023, these goals highlight the requirement of a Framework that integrates a range of services to support the physical, social, emotional, and educational development of Aboriginal and Torres Strait Islander young people from conception through to the foundation years of primary school. This also aligns to The Nest wellbeing framework for children and young people aged 0 to 24 years, which outlines the following domains Australian young people need in order to thrive (Goodhue et al. 2021):

1. Valued, loved, and safe
2. Material basics
3. Healthy
4. Learning
5. Participating
6. Positive sense of identity and culture

Whilst the Nest is not solely focused on Aboriginal and Torres Strait Islander children, it is a valuable reference-point when considering the holistic features of a Victorian Aboriginal Early Years Health Framework that incorporates a multi-dimensional approach alongside the principles of self-determination, participation and co-design.

Within the contexts of the socio-political, academic, and Aboriginal and Torres Strait Islander policy and priorities discussed above, the Aboriginal-led participation and design process to inform the development of a holistic Framework comes at an opportune moment. Aboriginal and Torres Strait Islander children born in Victoria after 2019 will only remember life in a post-Treaty society at a State level. This Framework will play a vital role, therefore, in preparing the Treaty Generation – a generation raised within supports and services underpinned by the principles of self-determination, reciprocity and voice.

To frame the discussion and vision of the Framework during workshops and forums, the central question must be asked: ‘What is a Victorian Early Years Health Framework?’.

State and Commonwealth policy, legislation, and initiatives

Whilst the answer to this question will ultimately be informed by Victorian and Commonwealth policy and legislation, and hence funding, it is worth evaluating this against other State-based strategies. In doing so, one can formulate a broader policy map that synthesises the governmental programs and initiatives designed to promote the physical, social, emotional and educational wellbeing and aspirations of Aboriginal and Torres Strait Islander children and families.

Victoria

Within Victoria, there are several relevant government frameworks and strategic plans that hold implications for the development of the Framework. In particular, the following should be considered:

Korin Korin Balit Djak: Aboriginal health, wellbeing and safety strategic plan 2017–2027

Korin Korin Balit Djak embraces a cultural determinants approach, it acknowledges the positive impact that cultural factors – such as identity, language, spirituality, and connection to Country, family and community – have on the lives of Indigenous people. Cultural determinants utilise strengths-based approaches and recognise the importance of self-determination, thereby aligning with the Indigenous holistic understanding of health (Victorian Government 2017a).

Prior to May 2023, Korin Korin Balit Djak was the overarching framework for action to advance self-determination and improve Aboriginal health, wellbeing and safety in Victoria. Due to the increased focus on health and wellbeing following the COVID-19 pandemic, a tier 1 policy document specific to Aboriginal health and wellbeing has been designed in partnership with the Aboriginal community-controlled health sector. The 10-year Aboriginal Health and Wellbeing Partnership Agreement 2023-33 (the Agreement) is a commitment from the Aboriginal Health and Wellbeing Partnership Forum (the Partnership Forum) members to work together in reforming the healthcare system, guided by self-determination, cultural safety, accountability and transparency.

The Agreement is supported by the Aboriginal Health and Wellbeing Action Plan 2023-25, which includes five domains and 15 self-determined priorities to improve Aboriginal health and wellbeing outcomes. Although early years and maternal and child health is not explicitly called out, the domains and self-determined priorities highlight the need for the sector to focus on prevention and early intervention, culturally safe healthcare, and a self-determined healthcare system.

The Partnership Forum is a strategic collaboration between the ACCHO sector, mainstream health sector and the Victorian Department of Health. It is jointly chaired by the Minister for Health and the Chairperson of the Victorian Aboriginal Community-Controlled Health Organisation (as received by Victorian Department of Health Aboriginal Health Division).

Victorian Aboriginal Affairs Framework (VAAF)

VAAF is an overarching policy guiding the Victorian Government's work with Aboriginal Victorians across multiple areas, including health, education and cultural integrity. It recognises the rights of Aboriginal people and their rich cultural heritage (Victorian Government 2018a).

VAAF’s inclusive and rights-based approach offers a vital reference point for the Framework, advocating for the cultural rights and holistic development of Aboriginal children. The VAAF reports on Koori Maternity Service attendance rates.

Wungurilwil Gapgapduir

The Wungurilwil Gapgapduir Aboriginal Children and Families Agreement and Strategic Action Plan sets out a partnership between the Victorian Government, Victorian Aboriginal Communities and the child and family services sector. It focuses on reducing the number of Aboriginal children in out-of-home care by building their connection to culture, Country and community. Self-determination is the overarching principle of this agreement, ensuring that Aboriginal communities are the primary guide for improved services and outcomes for Aboriginal children and families (Victorian Government 2018b).

This agreement outlines key objectives that will be useful to consider in the development of the Framework, including prioritising Aboriginal workforce capability and knowledge.

Maternal and Child Health Service framework

This framework provides an ‘integrated service delivery architecture’ for the Victorian Maternal and Child Health (MCH) Service – a free universal primary health service available for families with children from birth to school age (Victorian Government 2021:8). It consists of a range of guidelines and standards for service providers and families. The MCH Service provides a comprehensive approach for the ‘promotion, prevention and early identification of the physical, emotional and social factors affecting young children and their families’ (Victorian Government 2021:11). Further, it focuses on both maternal health and father-inclusive practice as key enablers to optimise child learning and development.

As outlined in Korin Korin Balit Djak, the MCH Service guidelines reiterate that self-determination is ‘the only policy approach that has produced effective and sustainable outcomes for Indigenous peoples’ (Victorian Government 2021:45). The guidelines discuss the importance of co-design in providing services that are culturally safe and responsive. There is a strong focus on ensuring Aboriginal staff are employed in MCH services and that strong relationships and partnerships are cultivated with ACCOs. These will be crucial considerations when developing an Aboriginal Early Years Health Framework.

Koori Maternity Services Guidelines

Koori Maternity Services (KMS) epitomise a flexible, holistic, and culturally attuned approach to prenatal and postnatal care catering to Aboriginal women, those bearing Aboriginal children, and their families. Administered by Aboriginal Community-Controlled Organisations (ACCOs) and public health entities, the KMS network spans 14 locales within Victoria, embedding itself as a vital facet of the regional maternity care infrastructure (Victorian Government 2017b).

The ethos of KMS hinges on a personalised, family-centric, and community-oriented model of care, which underpins the delivery of safe and superior quality services tailored for the Aboriginal populace. The collaborative ethos of KMS extends to forging partnerships with the women, families, and local communities they serve, ensuring the cultural appropriateness, responsiveness, and individualised tailoring of the services rendered.

Guiding the KMS operations is a set of guidelines, which not only lay down the service delivery mandates but also serve as a common platform for ACCOs, health service administrators, and the KMS workforce, furnishing them with requisite information and pragmatic counsel regarding program mandates. These guidelines are conceived in alignment with, and extend upon, the National Clinical Practice Guidelines for Antenatal Care – Modules I and II (Department of Health 2020).

Anchored by these guidelines, an annual regimen of local and statewide program scrutiny and oversight is enacted. This recurrent evaluative practice is envisaged to augment the calibre and safety of care accorded to the women and families patronising the services. The formulation of these guidelines was a collaborative endeavour, engaging the Victorian Aboriginal Community Controlled Health Organisation (VACCHO), the KMS workforce, and delegates from both urban and regional ACCOs and public health institutions.

Maternity and Newborn Capability Frameworks

The Maternity and Newborn Capability Frameworks serve as collaborative guides aiding clinicians, health services, and administrative departments in Victoria in structuring and managing maternity and newborn care. These frameworks streamline planning through pregnancy, birth, and postnatal stages, ensuring informed resource allocation and protocol adherence to address care complexities. They encourage localised planning and transparent service development aligned with community needs.

Outlined in the document "Capability Frameworks for Victorian Maternity and Newborn Services" (Department of Health, 2022), the frameworks categorise services across six levels, specifying requirements for a safe, high-calibre continuum of care. 'Capability' reflects the level of care a health service can consistently provide, including essential workforce, infrastructure, and clinical support services. The department, as the system manager, determines and communicates health services' capability levels, with a focus on regular reviews and planning for care level adjustments. These frameworks operate within the existing legislative and standard frameworks, aligning with stipulated care standards by Safer Care Victoria and the National Safety and Quality Health Service (NSQHS) Standards. This framework promotes cultural safety and care and referral to Aboriginal Hospital Liaison Officers.

Victorian action plan to prevent oral disease 2020–30

This action plan recognises the important role that oral health plays in overall general health and wellbeing, and commits to improving the oral health of Victorians, particularly children (as set out in Priority 1). It also focuses on promoting healthy environments and service systems that support good oral health, including ACCOs. The plan acknowledges the higher prevalence of advanced tooth decay in Aboriginal children and notes the importance of including oral health assessment in the Aboriginal children health assessment (Victorian Government 2020).

Given the disparities in oral health outcomes between Aboriginal and non-Aboriginal populations, incorporating a culturally specific oral health strategy into the Framework is crucial.

The Victorian Government’s policies and frameworks on early years health and education offer a strong foundation for creating the Framework. To be effective, this new framework should consider the unique needs, values and experiences of Aboriginal communities. Central to this is the emphasis on cultural integrity, community involvement and rights-based approaches. By integrating insights from existing policies and tailoring them to the Aboriginal context, a holistic and culturally responsive Framework for Aboriginal children can be developed. Delving into early childhood health policies in Victoria, it becomes evident that while there are comprehensive strategies in place, their effectiveness within the Aboriginal community hinges on cultural sensitivity and adaptability. For a holistic Framework to be successful, it needs to ensure that all aspects of early childhood health – from antenatal care to foundation years of primary school – respect and acknowledge Aboriginal traditions, values and experiences.

Yoorrook Justice Commission: Report into Victoria’s Child Protection and Criminal Justice Systems

The recent publication of the Yoorrook Justice Commission’s report into Victoria’s Child Protection and Criminal Justice Systems highlights the ongoing systemic racism that pervades the Victorian health system. This, along with ‘racist stereotypes and assumptions about Aboriginal mothers’ (Yoorrook Justice Commission 2023:134) contribute to a disproportionate representation of Aboriginal children in child protection, over-represented in the child protection system by 11:1 (Yoorrook 2023:24). This is evident in instances of pre-birth reports to child protection, with ‘491 pre-birth reports regarding First Peoples’ children,’ lodged in 2022 alone (cited in Yoorrook 2023:134) and ‘reports to child protection for unborn children are more than double those for non-Aboriginal children’ (cited in Yoorrook 2023:24).

Whilst child protection is not directly a responsibility of the Department of Health, there are a range of Governmental failings, including health, that are contributing to the over-representation of Aboriginal children in the child protection system. Furthermore, central to Report’s recommendations is the need for early help, prevention and intervention to circumvent the need for child protection involvement, a key focus the Department of Health has a role in. As asserted in the Report, ‘[i]t is a whole-of-government problem that requires whole-of-government effort (Yoorrook 2023:137). This was further reinforced by one witness who explained, ‘[w]e need…collaborative efforts from…health, from education, from a whole range of spaces, that prevent – that really wrap around families’ (Yoorrook 2023:128). Thus, it is incumbent on the Department of Health to develop an early years health Framework that, in part, provides adequate supports to parents with a focus on early help and prevention.

A key barrier that exists in the early years health space, however, is the inability to access culturally safe services. Families, consequently, lack trust in services that may provide early intervention and prevention support. For example, ‘Aboriginal women are judged if they do not voluntarily engage with services (that they may not trust) or meet the expectations of maternity staff (Yoorrook 2023:136). Therefore, the Report calls for the Victorian Government to provide direction to health services such as perinatal, maternal and child health services to ‘undertake appropriate training to address bias and build expertise in working safely and effectively with First Peoples women and families’ (Yoorrook 2023:30). This will increase the likelihood that families receive culturally safe, early and wrap around support from early years health services, concurrently decreasing the likelihood of child protection involvement. Therefore, the Framework must include provisions for cultural safety in mainstream early years health services delivered to Aboriginal and Torres Strait Islander families.

In conjunction with culturally safe early years health services, is the need for further investment in early help services that provide empowering support to parents such as Bendigo and District Aboriginal Cooperative’s Garinga Bupup program. Independent evaluations demonstrate that programs such as this that provide parenting support in a strengths-based way contributed to an increase in parents’ levels of trust, self-esteem, agency, and empowerment (Yoorrook 2023:137).

Additionally, there is a glaring need to revise approaches to funding of holistic early years services that can serve a prevention and early intervention role. Holistic early years services such as Bubup Wilam, Yappera and Berrimba are not currently categorised as prevention and early intervention services (Yoorrook 2023:133), and thus are not funded accordingly. Funding barriers also exist in fixed-terms arrangements that compromise the sustainability and reach of holistic services for families. Thus, a revised approach to funding under the Framework is recommended so that it is holistic in implementation, not simply in name only.

The Yoorrook Justice Commission’s report unveils the ongoing systemic racism in Victoria's health system, which has significantly contributed to the over-representation of Aboriginal children in child protection. As the report suggests, this issue requires a comprehensive, whole-of-government response that demands cohesive efforts from various sectors including health. The Department of Health is positioned to enact early interventions and help through an early years health Framework. Furthermore, the Framework should contribute to an increase in culturally safe services for Aboriginal and Torres Strait Islander families, and re-examine funding arrangements to ensure holistic services can support this prevention, early intervention, and early help space. Through these measures the Framework can help Aboriginal and Torres Strait Islander children and families feel safe and strong in their identity.

Other States and Territories

Through comparing Victorian-based strategies and policies to those across other States and Territories, further themes emerge for consideration in the Framework:

Queensland: Deadly Kids, Deadly Futures framework

Queensland’s Aboriginal and Torres Strait Islander Child Ear and Hearing Health Framework 2016-2026 aims to prevent and manage the impacts of middle ear disease for Aboriginal and Torres Strait Islander children and young people across the health, early childhood and education sectors (Queensland Government n.d.a.). This framework focuses on the social determinants of health that contribute to middle ear disease in Indigenous children. Importantly, it recognises the long-term ramifications of the disease for school readiness, communication skills, learning abilities, educational outcomes, family relationships, social skills and future employment outcomes.

While Victoria has a broader focus on oral health, Queensland's targeted approach to ear health in Indigenous communities presents an area that the Framework should further consider.

Western Australia: WA Aboriginal Health and Wellbeing Framework 2015–2030

This framework takes a comprehensive approach towards improving health outcomes for Aboriginal communities in WA. It underscores cultural determinants of health and wellbeing and promotes a community-driven approach (Government of Western Australia 2015).

This framework takes a life course approach, focusing on the broader factors and intergenerational mechanisms that affect health and wellbeing. Recognising the importance of good health care from preconception, the framework’s emphasis on prevention and early intervention is a valuable perspective that can guide the development of a holistic Framework.

Northern Territory: Starting Early for a Better Future – Early Childhood Development in the Northern Territory 2018-2028

This plan emphasises the significance of early years in shaping a child's future. With special consideration for the high Indigenous population in the NT, the plan aims to eliminate the gap between Aboriginal and non-Aboriginal children (NT Government 2018).

Like Queensland, this plan reiterates the importance of hearing health, and also has a strong focus on nutrition. Its coordinated and collaborative approach can serve as a model for Victoria in creating a dedicated Aboriginal Early Years Health Framework.

A survey of policies and frameworks across Australian States and Territories reveals a rich tapestry of approaches to Indigenous and early years health and education. Although Victoria boasts a robust framework, learning from the culturally-tailored, targeted and comprehensive strategies of other States and Territories can further enhance the development of a holistic Early Years Health Framework.

First 1000/2000 Days

The term "first 1,000 days" describes the period from conception until a child reaches the age of 2 years (24 months) (Early Moments Matter | UNICEF, n.d). This phase is particularly critical as it witnesses remarkable growth and development in a child’s brain, body, and immune system (Morris et al., 2022). Factors such as maternal health, nutrition, and stress during pregnancy can profoundly influence a child's future trajectory (Fitzgerald et. al, 2020; Hyde et al., 2021). Post-birth, the physical environment, dietary intake, relationships, and even playtime have an enduring impact on their long-term health and well-being. In recent years, there has been increasing recognition of the importance of the first 1,000 days in shaping a child's future (Lee & Ride, 2018; Gebremichael et al., 2021).

Brain development during these initial 1,000 days is unparalleled (Burger et al., 2022). Environmental adaptation during this period moulds the eventual persona of the child. Proper nutrition ensures optimal brain function, enhancing learning capabilities, physical skills, and emotional balance. Conversely, adverse conditions like malnourishment, undue stress, or exposure to abuse can jeopardise this development, leading to lifelong repercussions including deteriorated physical health (Simoncic et al., 2022).

In the context of Aboriginal and Torres Strait Islander children in Australia, the first 1,000 days take on even greater significance. Whilst many children thrive, some children face unique challenges and disparities that can have long-lasting effects on their health and well-being. Policymakers and healthcare providers must prioritise the well-being of mothers, fathers and carers of their Aboriginal infants during this critical window of opportunity (Dossetor et.al., 2023; Mitchell et al., 2023).

Nutrition stands as a cornerstone during these formative years. Maternal weight, lifestyle, and diet during pregnancy dictate the baby’s metabolism, immune function, and organ development (Musgrave et al., 2023). Inadequate nutrition can predispose the child to obesity, cardiovascular diseases, and stroke in later stages. Hence, expecting mothers are advised to maintain a balanced diet, with breastfeeding being highly recommended (Doherty et al., 2022; Gilbert et. al. 2023). Upon transitioning to solid foods, instilling healthy eating habits becomes paramount.

Another crucial aspect is the influence of social and environmental factors on Aboriginal and Torres Strait Islander children during the first 1,000 days. Living conditions and neighbourhood characteristics, including socioeconomic status, play a significant role in shaping a child's outcomes (Burton et. al. 2017). Children living in disadvantaged environments may experience higher levels of stress, limited access to healthcare and educational opportunities, and greater exposure to toxins and pollutants (Banovcinova et al., 2018).

Another aspect that cannot be overlooked is the role of stress and trauma. Experiencing high stress during pregnancy can hamper the baby's nervous system and growth, escalating the risk of diseases like hypertension, heart disorders, obesity, and diabetes later in life (Canavan et al., 2022; Nasir et. al., 2021). Expectant mothers or those with young children need to seek assistance if confronted with traumatic situations, for fear of transmitting intergenerational trauma (Meulewaeter et al., 2019; Zeanah et al., 2018). Safety, security, and nurturing relationships are indispensable for a child’s holistic growth (Bliznashka et al., 2021). Through healthy relationships, children comprehend the world around them, enhancing their cognitive and emotional intelligence.

Tackling poverty during this timeframe is vital, as there's a proven connection between Aboriginal childhoods, poverty and unfavourable health and psychological outcomes in adulthood (Bull et al., 2022). Parental stress stemming from financial struggles might hinder their ability to offer the necessary care. Yet, resilience can be fostered in children even amidst adversity. Solutions include seeking and accepting help, managing stress, ensuring emotional security for the child, and engaging in inexpensive family activities. For holistic growth, mothers are advised to prioritise a healthy diet during pregnancy, avoid harmful substances, and provide ample love and security to their children.

The First 1000 Days Australia model, led by Professor Kerry Arabena when at the University of Melbourne, acknowledges the importance of culture as a protective factor in ensuring the health and well-being of Aboriginal families (Moore et al., 2017). This comprehensive and culturally informed approach aims to address the specific needs of Aboriginal families by providing a coordinated and supportive strategy. The First 1000 Days Australia model recognizes the diversity and heterogeneity of Indigenous peoples and communities across Australia. By prioritising Indigenous knowledge and methodologies, it ensures that the strategies implemented are culturally adapted and relevant. The First 1000 Days Australia model emphasises community governance at regional and national levels, which promotes researcher accountability and collaboration among participating organisations (Ritte et al., 2016).

Through a year-long engagement process, the First 1000 Days Australia model aimed to link researchers, policymakers, professional associations, human rights activists, and community members to develop strategies that prioritise the needs and aspirations of Aboriginal and Torres Strait Islander children and families (Ritte, et. al. 2016). Furthermore, the First 1000 Days Australia model incorporates a strengths-based empowerment approach, focusing on the assets and resources within Aboriginal and Torres Strait Islander communities rather than solely on deficits. This strengths-based empowerment approach recognizes the resilience and potential of Aboriginal and Torres Strait Islander children and families, allowing for more effective interventions that promote healthy development and well-being (Kennedy, et. al., 2022).

In contrast, the 2000-day initiative expands the scope of intervention to include the critical period of early childhood development and education. The 2000-day initiative conceived of by non-Indigenous researchers at the Australian Prevention Partnership Centre, recognizes the significant impact that early education and care in the preschool years can have on all children. This concept was then adapted by the NSW government as a policy initiative to ensure long-term outcomes for Aboriginal and Torres Strait Islander children. Policy and programming focused on the first 2000 days, was later adopted by the Queensland government after being advocated for by the Clinical Senate Advisory Group, and featured in the Victorian policy landscape after being introduced by the Vichealth Local Government Partnership.

The period of time, 2000 days, advocated for by mainstream researchers in the fields of nutrition for example, has shifted the focus from the first 1000 days Australia model which centralised culture as the protective factor for parenting in Aboriginal families, to a focus on ‘caregiver behaviour’ (Love et. al. 2022), which, for First Nations families, has been a strong feature of engagement with child protection and judicial institutions in an Australian context. Expanded policy contexts which focus on the first 2000 days rarely contextualise parental behaviours within the history of colonialism and systemic racism that Indigenous communities have experienced (AHRC, 2015). Although there is an emerging body of research among Aboriginal midwives and researchers focusing on the life transitions that occur within the first 2000 days. Predominantly looking at whether perinatal services can safely identify Aboriginal parents with complex trauma, and reinstating cultural supports during pregnancy and birth (Chamberlain et. al., 2022).

By extending the focus to the first 2000 days, Aboriginal researchers are focused on life transitions in this initiative, seeking to ensure that Aboriginal and Torres Strait Islander children have access to quality health and education, early learning and care, as well as culturally responsive service delivery that reflects and respects their heritage and identity. This approach acknowledges that the first 2000 days of a child's life are crucial for setting strong foundations for learning and development. It recognizes that early childhood education and care play a vital role in promoting cognitive, social, and emotional development, as well as school readiness. Through the 2000-day initiative, efforts are made to address early childhood development and education disparities among Aboriginal and Torres Strait Islander children.

The First 1000 Days Australia model and the 2000-day initiative both aim to improve the health, well-being, and educational outcomes of Aboriginal and Torres Strait Islander children and families in Australia. The First 1000 Days Australia model and the 2000-day initiative are both crucial interventions that aim to address the health, well-being, and educational outcomes of Aboriginal and Torres Strait Islander children and families in Australia. The First 1000 Days Australia model is unique in its focus on Indigenous children across nations, incorporating Indigenous knowledge and methodologies to promote healthy development. The first 2000 days frameworks are informed by evidence that identification of complex trauma, early education and care in the preschool years has a significant impact on long-term outcomes (The First 2000 Days Framework, n.d).

By combining the knowledge gained from the First 1000 Days Australia model with the expanded focus on the evidence generated by Aboriginal researchers in the first 2000 days, there is a greater opportunity to support the holistic development of Aboriginal and Torres Strait Islander children (Ritte et al., 2016).

Commonwealth

Early Years Strategy

The Department of Social Services Early Years Strategy seeks to establish a holistic road map for the first five years of all Australian children (Australian Government 2023). In particular, the Strategy’s intention is to ‘create an integrated approach to the early years, including by reducing program and funding silos across Commonwealth departments and better integrating and coordinating functions’ (Australian Government 2023:5).

In seeking to improve the wellbeing, education, health, mental health, safety and development of Australia’s children, the Strategy focuses on ‘breaking down silos’ between Commonwealth departments (Australian Government 2023:6). The Strategy acknowledges that the current funding structure at a Commonwealth level inhibits an integrated delivery of early years services, and rather ‘discourage[s] collaboration across organisations [that] may hamper the Commonwealth’s efforts to deliver the best outcomes for children and families (Australian Government 2023:6).

Whilst a coordinated approach to service delivery in the early years will benefit the general population, for Aboriginal and Torres Strait Islander children and families this is especially paramount. For instance, the gap between Aboriginal and Torres Strait Islander children and non-Indigenous children increased to 24.7% in the language and cognitive development domain (Australian Government 2023:10). Through reducing funding silos, an integrated approach is more likely to reduce systemic and intergenerational disadvantage through wrap-around support. The Strategy discussion paper acknowledges that:

Families and communities who have been impacted by intergenerational trauma and discriminatory policies that perpetuate disadvantage often have complex needs, and are most in need of targeted and intensive healing and support services that are culturally-safe and welcoming. (Australian Government 2023:8)

The Strategy discussion paper, for instance, points to the Connected Beginnings program as one inter-departmental collaborative approach that aims to meet learning and developmental milestones to achieve school readiness (Australian Government 2023). Although the Victorian Aboriginal Early Years Health Framework is a Victorian Department of Health initiative, it is critical to consider its interconnectedness with other Departmental initiatives and programs, and methods through which coordination may be reached. Although in the immediate term this will be challenging, given a central priority at a Commonwealth level is to remove barriers to an interdisciplinary and collaborative approach it is recommended that the Department of Health urge the State Government to align its priorities with those outlined in the Strategy.

Where the Framework can more readily align with the priorities of the Strategy is through its strengths-based and child and family centred philosophy. The Strategy will acknowledge the significance of cultural identity and connection to children’s development, as well as reciprocal relationships and partnerships between service providers, families, and communities. It will also adopt an aspirational lens as opposed to a deficit lens. Thus, the Aboriginal-led design and participation process of developing the Framework is a critical element to ensuring it corresponds with the Strategy’s principles.

National Action Plan for the Health of Children and Young People

Due to social, geographical, and other determinants and inequities, children with an Aboriginal and Torres Strait Islander background have been identified as a priority population group at a national level in regard to health care and access (AIHW 2020; Australian Government 2019). This need is further reinforced by the subsequent disadvantages and barriers to accessing adequate and culturally safe health services. In turn, Aboriginal and Torres Strait Islander populations are more likely to experience poorer health outcomes that span all stages of life (Australian Government 2019).

In regard to early years health, Aboriginal and Torres Strait Islander children are ‘twice as likely to be developmentally vulnerable in one or more areas’ and ‘less likely to have ever received breastmilk’ (Australian Government 2019:8). The Australian Department of Health and Aged Care’s National Action Plan for the Health of Children and Young People 2020–2030, therefore, outlines key commitments to be considered in the development of the Framework. These include:

• Improving the evidence base to better target need and efficacy of interventions: namely, an emphasis on improving the evidence base for programs targeted at Aboriginal and Torres Strait Islander children and young people. As part of this, it is essential to note that in the development of the Framework, Aboriginal-led and community-led evidence will contribute to a more responsive, culturally safe, and accessible suite of services.
• Embed and develop related activities in accordance with frameworks developed for priority populations: in particular, developing and implementing future activities which align to current frameworks for Aboriginal and Torres Strait Islander Australians. This speaks to the need for the Framework to be embedded seamlessly within other state-based and national policies, strategies, and initiatives.
• Promote and increase uptake of programs and initiatives directed at the health of children and young people: in this case, it is critical that the Framework redresses current inequities and barriers to accessing programs and initiatives by further enhancing the cultural safety and responsiveness of services for Aboriginal and Torres Strait Islander peoples.
• Increase roll out of proven home-based initiatives supporting parents in the antenatal and perinatal stage, especially among priority populations: specifically, the need to trial and evaluate adapted evidence-based programs, co-designed with communities for use with Aboriginal and Torres Strait Islander families. Hence, the Aboriginal-led participation and design process aligns with this action.
• Develop workforce capacity and capability in relation to trauma awareness and trauma-informed practice: ideally, the Framework will be delivered by community-controlled organisations, acknowledging that they are the experts in the needs, experiences, and perspectives of their communities. It is critical that the Framework encompasses trauma-informed care and training for mainstream services and non-Indigenous staff.
• Enhance mechanisms to support paediatricians, GPs, child and family nurses, midwives and other health professionals to identify and address underlying factors shaping health outcomes: the use of standardised tools for health assessment of Aboriginal and Torres Strait Islander children to aid in identifying underlying risk factors should be included and/or developed as part of the Framework.

The actions outlined here will influence key priorities and strategies as part of the Framework both on both a holistic and programmatic level. When considering mechanisms and benchmarks for access to culturally safe services and programs, for instance, the Framework may specify macro-level competencies and targets applicable to multiple streams of care. However, on a programmatic level, it is essential for the Framework to synthesise and align national service-specific action plans, strategies, and policies with Framework priorities. The National Immunisation Strategy for Australia 2019–2024, for instance, establishes key targets and actions to achieve and maintain high immunisation rates among Aboriginal and Torres Strait Islander peoples (Australian Government 2019). In particular, the Immunisation Strategy emphasises the importance of culturally safe resources and workers, as well as specific follow-up programs for Aboriginal and Torres Strait Islander peoples. This National level strategy, therefore, may inform immunisation strategies and initiatives embodied in the Victorian Aboriginal Early Years Health Framework, ensuring that Aboriginal and Torres Strait Islander children and families have access to culturally safe immunisation and follow-up services.

United Nations and World Health Organisation Priorities

Article 18.2. For the purpose of guaranteeing and promoting the rights set forth in the present Convention, States Parties shall render appropriate assistance to parents and legal guardians in the performance of their child-rearing responsibilities and shall ensure the development of institutions, facilities and services for the care of children. (UNCRC 1989)

The rights of children are recognised in key international instruments. Relevantly, article 24 of the United Nations Convention on the Rights of the Child (UN 1989) states that all children have the right to enjoy the highest attainable standard of health and access to health care services. Article 24 also sets out that States Parties shall take appropriate measures including to ensure pre- and post-natal health care for mothers, to ensure access to education, to combat disease and to develop preventive health care. The UNCRC institutes the obligations of States to provide adequate services that support both parents and children to ensure that ‘the best interests of the child shall be a primary consideration’ without any form of discrimination (UNCRC 1989). A Framework that redresses systemic inequities preventing Aboriginal and Torres Strait Islander children and families from accessing adequate health care is, thus, imperative.

Further, the United Nations Declaration on the Rights of Indigenous Peoples (UNDRIP) (UN 2007:5) recognises ‘the right of Indigenous families and communities to retain shared responsibility for the upbringing, training, education and well-being of their children, consistent with the rights of the child’. Article 24 of the UNDRIP also states that Indigenous peoples have an equal right to the enjoyment of the highest attainable standard of physical and mental health. This is in-line with Goal 3 of the United Nations Sustainable Development Goals Report, ‘Ensure Healthy Lives and Promote Well-Being for All at All Ages’ (UNDESA 2022), with a particular focus on access to immunisation amongst young people and the health of mothers.

In addition to the obligations set out by the United Nations, international strategies and initiatives further advocate for a holistic approach to early childhood health and development. The Nurturing Care for Early Childhood Development Framework, for example, signifies the components of nurturing care through this integrated lens through encompassing: Good Health; Adequate Nutrition; Responsive Caregiving; Security and Safety; and Opportunities for Early Learning (WHO, UNICEF and World Bank Group 2018). Subsequently, the WHO guidelines for Early Childhood Development (WHO 2020) advocates interventions related to improving early children’s health, responsive caregiving, and early learning opportunities. The WHO key recommendations focus on targeting the first three years of infant and child development through a holistic process encompassing caregiving, early learning, nutrition. Additionally, the WHO promotes the support of maternal mental health, highlighting the need for interventions to be integrated within early childhood health and development services (WHO 2020).

Hence, guided by the principles of human rights and international imperatives that advocate for equitable access to holistic early years health and development for all Indigenous children, it is evident that the Framework must be underpinned and guided by a similar ethos. Due to systemic barriers resulting from the historical and contemporary effects of colonisation within Victoria, not all Aboriginal and Torres Strait Islander children and families have experienced this fundamental right. It is critical that the Framework redresses these historical and contemporary inequities through a coordinated approach as endorsed by the United Nations and World Health Organisation.

International Indigenous Examples

It cannot be ignored that the experience of colonisation for Aboriginal and Torres Strait Islander peoples is unique due to the fallacy of ‘Terra Nullius’, a doctrine leading to oppressive and destructive early-settler policies with severe impacts for communities that pre-date settlement. The resulting intergenerational trauma that has pervaded Aboriginal and Torres Strait Islander peoples, coupled with ongoing systemic, structural inequities and injustices have perpetuated disadvantage. Yet, despite the unique history of Australia’s settlement, the detrimental effects of colonisation on Indigenous peoples is not exclusive to Aboriginal and Torres Strait Islander peoples. In particular, it is pertinent to examine the experiences of countries with similar histories to Australia, such as Aotearoa New Zealand and Canada, and the resulting early years strategies and initiatives implemented in these contexts to redress disadvantages in the early years. As Kral et al. posit:

‘Indigenous communities in Aotearoa New Zealand, Australia and Canada share a legacy of colonisation and assimilation. The detrimental effects of early settler-colonial policies are still evident today in many families and communities. With the reclaiming of cultural identity and sovereignty from the late 20th century, Indigenous communities around the world have focused on the next generation to keep languages and cultures strong. This places a particular focus on early years policies as a locus for utilising Indigenous cultural knowledge frameworks and strengthening Indigenous communities’. (Kral et al. 2021:8)

Across these international contexts, Kral et al. emphasise the importance of developing programmes that reflect the cultural views and priorities of Indigenous peoples through a holistic, strengths-based approach and close consultation with Indigenous communities. The measure of success of such holistic programmes should not simply focus on individual child outcomes, but also in the way it ‘meet[s] the aspirations of Indigenous families and communities’ (Kral et al. 2021:9). The Aboriginal-led participation and design process of the Framework, therefore, is in keeping with these principles of self-determination recognised as critical for Indigenous peoples internationally. Furthermore, when determining the evaluation criteria and subsequent Impact Assessment Tools of the Framework, it must assess beyond the individual child, and incorporate an aspirational family and community lens.

Aotearoa New Zealand

As Victoria undertakes Treaty negotiations between the First Peoples’ Assembly of Victoria and the Government of Victoria, it is worth examining the health policies and strategies of Australia’s antipodean neighbours whose Government is informed by the Treaty of Waitangi.

The principles underpinning the Treaty of Waitangi forms the basis of partnership between Maori and the New Zealand Government. Guided by the Treaty, Maori have the inherent right to make decisions about the planning and delivery of health services.

Within a health context, an essential priority of the New Zealand Government is to embed the Te Tiriti o Waitangi across the health sector (MoH 2022). To ensure this priority is achieved, the New Zealand Ministry of Health’s objectives focus on increasing Maori partnerships, governance, the capacity of the workforce, and Maori-led health services (MoH 2022) to further address inequities in health outcomes.

Specifically for Maternity and Early Years health, Health New Zealand is employing the Kahu Taurima strategy that is informed by the First 2000 Days model. The aim of the strategy is to ‘design and commission new integrated, culturally tailored services and programmes for all maternity and early years’ across 2023-2024 (HNZ 2023). The Kahu Taurima initiative aims to reduce barriers and silos in existing service models while contributing to enhanced integration between primary care, community and specialist services. Furthermore, it intends to enhance culturally affirming health services while providing wrap-around support for children and families (HNZ 2023). For Maori children and families, in particular, there is an emphasis on commissioning Hauora Maori Partners to deliver maternity and early years services so that care is culturally responsive and accessible.

The Victorian Department of Health has an opportunity to be at the forefront of embedding principles of Treaty within an Australian context. By looking to Aotearoa New Zealand, the development of the Framework can look to further enhance Indigenous-led service delivery, and greater coordination and integration between services to ultimately contribute to a culturally affirming, responsive, and accessible early years health service for Aboriginal and Torres Strait Islander peoples.

The Royal Australasian College of Physicians: Indigenous Child Health in Australia and Aotearoa New Zealand

The RACP commissioned a position statement in 2020 examining the current state of health of Indigenous children in both Australia and Aotearoa New Zealand, and disparities in outcomes compared to non-Indigenous children (RACP 2020). The position statement outlines the RACP’s role in eliminating health inequities. Of particular note, the RACP asserts that:

• Indigenous Child Health is everyone’s responsibility
• Indigenous child health care works best when designed and delivered by Indigenous people
• Paediatricians improve Indigenous child health when they support and work with Indigenous communities
• The RACP is committed to the development of an Indigenous physician workforce that mirrors the population. (RACP 2020:5-6)

For paediatricians and paediatric trainees, therefore, the RACP position statement underscores the importance of increasing cultural competency through formal and informal methods. This may include cultural competency training, or methods such as learning about local Indigenous culture and language. Through doing so, the RACP hopes to increase the cultural safety and responsiveness of child health care to Indigenous children in both Australia and Aotearoa New Zealand.

Specifically relating to Aotearoa New Zealand’s Maori population, the RACP acknowledges Maori models of health - one that focuses on holistic wellbeing. In particular, the RACP recognises Maori wellbeing as being dependent on the ‘equilibrium’ between the physical, mind, spiritual, and connection within family, kinship, and community (RACP 2020:8). This parallels with Aboriginal and Torres Strait Islander peoples view of health, and thus commonalities in developing responsive child health care models emerge.

Although the health status of Maori has been gradually improving, the RACP reports there are still significant inequities in health and social outcomes. For instance, ‘Maori children aged 0-14 are 1.6 times more likely to have teeth extracted due to decay, abscess or infection…[and] are 1.4 times more likely to have unmet need for primary care’ (cited in RACP 2020:13). Several approaches to Indigenous Health in Aotearoa New Zealand seek to address health system disadvantages:

• Whanau Ora philosophy: The Whanau Ora health initiative is implemented through a joint partnership between the Ministry for Maori Development (Te Puni Kokiri), the Ministry of Social Development, and the Ministry of Health. It is a strengths-based initiative that aims to empower families, rather than focus on a deficit-lens, and applies a holistic perspective that incorporates a range of influencing factors on well-being such as health, education, housing, employment, standards of living and cultural identity. (RACP 2020:28)
• Tino Rangatiratanga: This concept of self-determination is embedded within the principles of the Treaty of Waitangi, and thus speaks to the importance of Maori being represented in the health workforce and also the significance of Maori organisations planning and controlling services. Similarly to Aboriginal Community Controlled Organisations, Maori-led service delivery will increase child health service accessibility. The Waitangi Tribunal, thus, recommends the formation of a Maori health authority separate from the New Zealand Ministry of Health (RACP 2020:29).

Tipu Ora is one such example of a child health service embedding these principles of Treaty and Maori Health Models of care. Through this model, Maori community members and clinicians work in partnership to deliver child and maternal health services, parenting support, education, and dental services (RACP 2020:33). Significantly, Tipu Ora involves kuia (elderly Maori women) to work alongside Registered Nurses and social workers in the delivery of health education to parents. Furthermore, governance is Maori-led through the Tumu Whakarae of Manaaki Ora Trust, and paediatricians and health workers are encouraged to build relationships with local Maori leaders.

Whilst Treaty is not yet formalised in Victoria, through considering national and local initiatives that aim to reduce child health inequities for Maori children and families in Aotearoa New Zealand, the Victorian Department of Health has the opportunity to embed similar principles within the Framework. Through ensuring, where possible, that child health service delivery and governance is Aboriginal-led can solidify self-determination. This can further be realised through promoting partnerships with Aboriginal community members in the design and implementation of services that enhance the health and social and emotional wellbeing of Aboriginal children.

The Southern Initiative’s Early Years Challenge

The Southern Initiative’s Early Years Challenge, conducted in South Auckland, aims to understand the daily experiences and needs of young families during the first thousand days of a child’s life (The Southern Initiative 2017). In designing and evaluating the Challenge, a study analysed both qualitative and quantitative data, and conducted research through a co-design, strength-based approach to identify the strengths and specific challenges faced by Maori and Pasifika families in South Auckland. In particular, the study examined factors that inhibit parent capacity to care for their children, focusing on ‘parents as the primary nurturers of outcomes for children’ (SI 2017:6). Therefore, the Challenge targets the consequential impact stressors and inhibitors on parents can influence child development during their first thousand days.

The Southern Initiative adopted a family-centred co-design approach for the Early Years Challenge, using an Indigenous methodology of kaupapa Māori framework to ensure a culturally appropriate process (SI 2017:8). The Challenge’s strengths-based approach focuses on capacity building, and social connectedness and social capital for families within communities. Furthermore, the Challenge intends to formulate a partnership between the Southern Initiative and communities to ensure solutions to early years challenges are fit for purpose and sustainable. This was largely informed by the Maori concept of ‘Mana’, acknowledging that families ‘are the experts in their own lives’ (SI 2017: 11).

The resulting study concluded that families and young children in South Auckland are carrying a ‘heavy burden of toxic stress’ (SI 2017:3), which affects the wellbeing of future generations. Through the qualitative and quantitative data analysis, the study found that childrens’ wellbeing is dependent on parent wellbeing, therefore highlighting the need for the Challenge to reduce system-based stressors such as the way services are delivered. Consequently, the study recommends empowering parents through providing respite from stress and creating support networks through community connections. To do this, the Challenge provides a ‘biodegradable’ approach to supporting parents, employing coaches that focus on developing skills and confidence for parents, but also to focus on building relationships (SI 2017:23).

Ultimately, the Challenge advocates for reducing the myriad of stressors that influence both parent and child wellbeing during the early years. For instance, this may include co-creating programmes with parents and creating welcoming environments in both community and service delivery spaces (SI 2017:33). Furthermore, the Challenge promotes parent agency in developing and enhancing community services and spaces so that they are more likely to enhance wellbeing rather than contribute to stress (SI 2017:36).

It follows, therefore, that the Framework should similarly seek to address systemic stressors for parents with young children. Initially, it should aim to reduce system-based stressors and barriers that prevent adequate access to early years health services, for instance by involving parents in the co-creation of programmes. Through adopting a family-centred and strengths-based approach the Framework can empower parents, acknowledging their expertise in their own lives. The Framework also has the potential to provide support to parents through strategies such as coaching and creating community connections through service delivery. Most importantly, the Framework should promote collaboration and integration between communities and organisations so that services are culturally appropriate, responsive to community needs, and sustainable.

Canada

Similarly to New Zealand and Australia, Canada’s Indigenous peoples experience significant disparities in health care and health outcomes compared to non-Indigenous Canadians. As explained by Allen et al.:

[t]oo many First Nations, Inuit, and Metis Peoples in Canada face alarming health inequities, subpar access to health care, and culturally discontinuous services - a legacy of the sociohistorical realities of colonialism and racism that included systematic suppression of traditional Indigenous health knowledge and healing practices (Allen et al. 2020:208)

In turn, Allen et al. call for increased Indigenous-led health partnerships in Canada to ensure that health services reflect the cultural worldviews of Indigenous peoples, adopt a strengths-based and trauma-informed approach that redresses intergenerational trauma resulting from colonial policies, and that incorporates a holistic understanding of Indigenous models of health. In doing so, Allen et al. posit that health services in Canada can begin to address ‘health inequities that have arisen from complex historical and contemporary traumas faced by many Indigenous communities (Allen et al. 2020:208-209).

Aboriginal Head Start in Urban and Northern Communities Program

One such program that seeks to reverse these health inequities is The Aboriginal Head Start in Urban and Northern Communities Program. This Program targets Indigenous children living off-reserve at 134 sites across Canada (Health Canada and Public Health Agency of Canada 2017). Through the program, funding is provided to Indigenous-led community organisations to deliver holistic programs to ‘enhance the spiritual, emotional, physical and social well-being of Indigenous children aged 0-6 and their families’ (HC and PHAoC 2017:2). The Program aims to empower families and caregivers to have agency over the health and wellbeing of their children encompassing holistic health, nutrition, education, culture, and social support.

The evaluation’s findings identified the continued need for the Program, and the broader need for culturally appropriate and holistic programming. Evaluation indicators suggest the Program has, overall, been effective in meeting its aims. The Program has increased school readiness through increased language, motor and academic skills and other developmental benefits, with 93% of parents reporting that their child was more prepared for school due to their participation in the Program (HC and PHAoC 2017:29). There is also evidence to suggest that the Program has contributed to an overall improvement in Indigenous health and wellbeing for participants. Graduates of the program reported that they were provided ‘with a safe and supportive environment that included parents, family members, Elders, and the community as a whole’, in alignment with the Program’s aim to support families in ensuring healthy child development and family connectedness as determinants of wellbeing.

On the other hand, several logistical and geographical factors lead to inconsistent service delivery, and there were particular gaps in effective support for children with additional needs. Therefore, the evaluation recommends increased collaboration and integration between service providers and increased funding to support the workforce to meet the diverse needs of children.

For the Framework, therefore, it is crucial to consider the holistic needs of Aboriginal families and children, and ways in which it can empower families and strengthen community networks in a similar vein to the Program. It may also look to the Program’s resulting need for greater integration of services and strong investment in the workforce to ensure they are able to meet the individual needs of children and families, particularly in complex examples of intersectional requirements.

Perinatal

Baggarrook midwifery care

Baggarrook midwifery care provides Aboriginal and Torres Strait Islander families with one dedicated midwife throughout pregnancy, birth and postpartum. There are also other Baggarrook midwives available to provide ‘back up’ if needed. A monthly ‘Meet your midwife’ evening allows families to meet all of the midwives in the team. The midwives work closely with the Aboriginal Health team from Badjurr-Bulok Wilam and, if needed, other specialist services to provide appropriate care and support. This model of care also includes a monthly yarning circle called Baggarrook Gathering, giving new mums and mums-to-be a chance to meet other First Nations families (The Women’s n.d.).

Baggarrook was developed by Latrobe University in partnership with the Victorian Aboriginal Community Controlled Health Organisation (VACCHO), as well as participating health services and their First Nations health units. Although caseload midwifery is associated with ‘substantially better perinatal health outcomes’, few First Nations women receive it (McLachlan et al. 2022:1). This culturally responsive caseload midwifery service was co-designed to improve health outcomes for First Nations mothers and babies, including issues such as pregnancy loss, perinatal and maternal mortality, preterm birth, low birthweight and special care nursery admissions (McLachlan et al. 2022). The model of care was implemented in three major metropolitan maternity services between 2017 and 2020, with the sites achieving a 21-fold increase in access to the caseload midwifery model for First Nations women (90% of women who were offered the culturally specific model accepted it). This showed a stark improvement, with 703 First Nations women receiving the care, compared to only 34 who previously received caseload midwifery care at these sites.

Key contributors to the successful model implementation included:

• being First Nations’ community-driven and endorsed;
• collaborative efforts involving strong commitment from partner organisations;
• having a research team with significant technical expertise in implementing caseload models
• funding to support the process; and
• early and ongoing consultation, collaboration and engagement with key First Nations community stakeholders.

Remarkably, this implementation study demonstrated the rare, yet crucial, achievement of successfully translating gold standard evidence into practice on a large scale (McLachlan et al. 2022). The study authors suggest a prioritised expansion of the model, and emphasise the need for additional research focused on understanding the essential aspects of sustaining the model and further strengthening the partnership between First Nations and mainstream health services.

Waijungbah Jarjums

Waijungbah Jarjums is a co-designed model of care developed by the local Aboriginal and Torres Strait Islander community alongside the Gold Coast Hospital and Health Service, Women’s Newborn and Children’s Service. The innovative model is founded on Aboriginal and Torres Strait Islander ways of knowing, being and doing, combining both ‘Birthing on Country’ and ‘First 1000 Days Australia’ principles (Queensland Government n.d.b). The service offers continuity of care by a known Aboriginal and Torres Strait Islander midwife and child health nurse from conception to the first 1000 days (two years of age). Services include antenatal and postnatal education, breastfeeding support, health screenings and assessments, cultural connection and community events, and home visits. The program has reported improved low birth weights, increased numbers of mothers choosing to breastfeed, a reduction in premature births, and higher attendances for antenatal appointments (Queensland Government n.d.c).

A 2020 evaluation found Waijungbah Jarjums to be ‘an effective and cost-effective, clinically and culturally safe model of care’ (Queensland Government 2020:5). Key aspects of the model of care include cultural safety (workforce, environments, resources), continuity of care, equity in access to services, community control, First Nations staff, and strong partnerships with local Aboriginal and/or Torres Strait Islander organisations and communities (Queensland Government 2020).

Birthing

Culturally Safe Birthing

Culturally Safe Birthing is becoming a key focus for attention in the Victorian health service delivery system (Richards, D., & Foale, A. 2011). In recent years, there has been a growing call for evidence-based practices that cater to the unique needs of First Nations babies, particularly in urban settings (Developing and evaluating Birthing on Country services for First ..., n.d). There are comprehensive case studies illuminating the tangible benefits of the national Birthing on Country (BoC) policy (Developing and evaluating Birthing on Country services for First ..., n.d).n. Within the Birthing in Our Community (BiOC) service, researchers observed significant improvements including an early decline in preterm birth, holding significance amidst global concerns over rising preterm birth rates.

This is especially impactful given the absence of best practices to counter this concern, especially among socially disadvantaged women in affluent nations (Project20: Does continuity of care and community-based antenatal ... - PLOS, n.d). Within the Australian First Nations context, these findings underscore the effectiveness of community-centric, co-designed initiatives. This is despite ongoing governmental shortcomings in achieving meaningful outcomes, including the implementation of the 'Closing the Gap Strategy', enhancing child mortality rates and life expectancy, and addressing the persistent national preterm birth disparity.

First Nations leaders are championing structural shifts that enhance self-determination, leadership, and control over health services, as advocated by both national and international declarations, such as the UN Declaration on the Rights of Indigenous Peoples. One of the pivotal strategies employed by the BiOC was bolstering First Nations' governance, especially when redesigning services for Australian First Nations. This was made possible through unified visions, committed leadership, and fostering trust between stakeholders (Effect of a Birthing on Country service redesign on maternal and ..., n.d).

The BiOC's continuous midwifery care approach differs from the conventional model. It delves beyond physical care to address the social, cultural, spiritual, and psychological well-being of women and their families (Midwife-led Continuity of Care (MLCC) - International Confederation of ..., n.d). This holistic perspective resonates deeply with the National Aboriginal and Torres Strait Islander Health Plan, which underscores a comprehensive view of health, advocating for programs that bolster health, emotional well-being, and resilience. However, challenges persist. The absence of appropriate insurance for Aboriginal Community-controlled health services and inadequate funding via the primary health care funding scheme (Medicare) obstruct the broader adoption of BoC services and midwifery care. Solutions are primarily in the hands of the Commonwealth Government, demanding immediate and decisive action.

The BiOC service has shown that embedding culture in health practices is essential. Addressing systemic racism, this program not only enhances health outcomes but also addresses the broader social determinants of health. The model promotes cultural safety by incorporating family support workers who connect women to vital services, ensuring integrated and comprehensive care. This case study affirms the tangible benefits of community-centric, co-designed health initiatives for First Nations babies. There remains an urgent need for structural reforms to enhance the availability and quality of these services.

"Replanting the Birthing Trees" represents a strategic effort targeting the early years in Aboriginal Victorians. Addressing the significant challenge of intergenerational trauma, this project emphasises the pivotal role of early intervention in transforming detrimental cycles of trauma into nurturing and recovery. Intergenerational trauma refers to the transmission of trauma from one generation to the next. This trauma is experienced by Aboriginal populations, whose identity, culture, ways of life, and interactions were radically altered by colonial injuries (Santiago et al., 2022). Research has shown that the collective experience of colonial injuries has had long-term psychological and physiological effects on contemporary Aboriginal peoples, including higher rates of depression, suicidality, and substance use disorders compared to non-Aboriginal populations.

To address this issue, the "Replanting the Birthing Trees" project takes a holistic and culturally responsive approach. Rooted deeply in Indigenous traditions and knowledge, the project synergizes Aboriginal and Torres Strait Islander ways of knowing, being, and doing. Furthermore, it combines this indigenous wisdom with contemporary evidence-informed practices, following a co-design and research methodology referred to as Garma. This approach ensures that the project is culturally and contextually relevant to Aboriginal Victorians. The project is currently being implemented across seven perinatal services in Western Australia and Victoria, to redirect the intergenerational trajectory from trauma and harm to one of nurturing, recovery, and resilience.

Drawing from the lessons of the BiOC and "Replanting the Birthing Trees" projects, the Framework in Victoria should be community-centric, evidence-based, culturally integrated, and holistic. It must also be supported by structural and policy reforms, emphasising Indigenous governance, leadership, and collaborative multidisciplinary approaches.

Maternity Care

The Aboriginal community and Victorian Government has established targets in which all children thrive and flourish. In setting this target, in a Victorian context at least, it is important that the Framework recognises that:

Children who are raised in environments that affirm their cultural and ancestral lineage grow up feeling grounded, secure, and self-assured. Traditional stories, customs, languages, and ceremonies are integral in forming this identity and should be preserved and taught with pride.

Families and communities play pivotal roles in shaping the worldviews, morals, and values of young people. Strong families and tight-knit communities provide a support system, ensuring that young ones grow up with positive role models and a sense of belonging.

The importance of culturally sensitive and appropriate services cannot be overstated. Services tailored to the unique needs and nuances of Aboriginal communities — from prenatal care to early childhood education — are more effective. They take into account traditional practices, beliefs, and the historical and socio-political contexts of these communities.

The over-representation of Aboriginal young people in care systems is a concern. This can often result from systemic issues, including racism, socio-economic factors, and past policies of forced removals. Addressing these systemic issues and providing community-led solutions and interventions can help in reducing the number of young Aboriginal people in care.

Educating not just the Aboriginal communities but also the wider society about Aboriginal history, culture, and traditions can foster mutual respect and understanding. An educated society is less likely to harbour prejudices and biases.

It is essential to involve Aboriginal communities in decision-making processes, especially those that directly impact them. This fosters a sense of ownership and ensures that the decisions made are in the best interest of the community.

Recognizing and addressing historical traumas that Aboriginal communities have faced is essential. Programs that offer counselling, healing, and other forms of support can help in mending the wounds of the past.

By committing to these principles and continuously striving to create an inclusive, respectful, and nurturing environment, we can indeed ensure that every Aboriginal child has the best start in life.

Currently, Aboriginal children continue to be removed from their families and placed in the out-of-home care system at rates significantly higher than non-Aboriginal children. Although the number and rate of Aboriginal children in care has remained stable since the last reporting period, in 2021-22 the difference in rate between Aboriginal children and non-Aboriginal children in care increased. Increasing the proportion of Aboriginal children and young people being placed with Aboriginal carers or relatives is a key focus. Legislation has also been introduced to expand the role of ACCOs in delivering children and family services. More needs to be done to prevent Aboriginal children from being removed from their families in the first place, building on early support for families through maternity services and healthy relationship programs.

The new approach to cultural support planning for Aboriginal children now has ACCOs overseeing this process and endorsing the plans. This planning is supported by the cultural portal auspiced by VACCA and the recently funded Aboriginal kinship finding service.

There is a noticeable improvement in several measures, such as the attendance at Koori Maternity Services and significant gains in immunisation rates for Aboriginal children over the past decade. However, there was a reduction in the number of Aboriginal children (0-5 years) attending both Supported Playgroups and Koorie Supported Playgroups in 2021 due to the COVID-19 pandemic.

Measures indicate that the number and rate of Aboriginal children in care remain high and increasing. Although there is a strong focus on placing Aboriginal children with their families or other Aboriginal carers, many are still placed in non-Aboriginal residential care. One major goal is to improve the number and proportion of Aboriginal children in care who have a cultural plan to help them maintain and strengthen their cultural identity.

There is a clear need for continuous support and funding for programs that have shown progress. A multi-faceted approach to reduce the number of Aboriginal children in care, focusing on preventive measures and early interventions, seems crucial.

Improving self-determined models for care and amplifying the role of Aboriginal Community Controlled Organisations could further bridge the gap and cater to the unique needs of the Aboriginal community.

Maternal and Child Health

Mallee District Aboriginal Services - Early Years Service

The Early Years Services provided by Mallee District Aboriginal Services offers a range of specialised services for First Nations families from conception to school entry. The service is strengths-based and supports the ability of mothers and fathers to grow confidence in their role as parents, fostering healthy and resilient families. It also aims to improve health outcomes for children, ensuring any health or developmental concerns are addressed early (MDAS n.d.:60). The Early Years Services include KMS, Maternal and Child Health Service, Early Learning and Early Years Groups, and Early Years Support Services. The provision of services together in the one location allows for a high level of coordination across services at both worker and management level. A 2016 evaluation of the Early Years Services found that the grouping of services under a common umbrella ‘enables a comprehensive, intensive and increasingly integrated service to be provided to clients’ (Keating et al. 2016:70). After only four years, the Early Years Services was found to be highly effective, with data showing an increasing number of women receiving regular antenatal checks and very high proportions of children up to date with immunisation schedules and MCH visits. Further, no children receiving family support services were permanently removed from their parents’ care.

Connected Beginnings

Connected Beginnings is a grants program aimed at increasing Aboriginal and Torres Strait Islander children’s and families’ engagement with health and early childhood education and care. Jointly delivered by the Australian Government Departments of Education, and Health and Aged Care in partnership with SNAICC National Voice of our Children and the National Aboriginal Community Controlled Health Organisation (NACCHO), the program focuses on ensuring that early childhood services all work together to help First Nations children and families use the services they need. These include maternal and child health services, early childhood education and care services, family support services, preschools and schools, and council and local government support (Australian Government n.d.).

Connected Beginnings is a Closing the Gap measure, supporting all Closing the Gap priority reforms and focusing on targets 2, 3 and 4. The program has been progressively implemented since July 2016 and now supports 40 sites across every State and Territory in Australia. Key features of the program include that it is community owned and led, and it is place-based, therefore tailored to meet the unique requirements of the local community. The program utilises a collective impact approach, fostering collaboration among community members and organisations to identify the community’s strengths and issues, co-design solutions, and fund solutions according to local priorities and needs.

An evaluation of the program, published in 2019, found that Connected Beginnings ‘can provide an effective framework to support the integration of services across health, education and family support systems’, with progress evident at all sites (AHA 2019:4). The evaluation found the following defining features of the program:

1. Community-driven and flexible approach (collective impact & place-based approaches).
2. Funded organisations have connections to the wider service system.
3. Education-funded organisation and Health-funded organisation at most sites, enabling greater collaboration and integration of early childhood services.

Since this evaluation, Connected Beginnings has continued to grow, with the government committing $81.8 million to expand the program to 50 sites by 2025. Encouragingly, the average attendance of First Nations children in centre-based care increased by more than 10 per cent from 2019 to 2022 (Aly & McCarthy 2023). The number of children on track in all five Australian Early Development Census domains has also increased, demonstrating the value of place-based, community-led programs.

Deadly Ears

Deadly Ears is Queensland Health's Statewide program addressing Aboriginal and Torres Strait Islander ear health. This multifaceted program operates across various fronts, including delivering essential clinical services and fostering local capacity across 11 partner locations in rural and remote Queensland. Moreover, it coordinates policy and practice changes spanning health care, early childhood and education sectors, while also providing workforce training and professional development for health care professionals and educators. The program also extends to conducting research aimed at refining prevention, treatment and management strategies for middle ear disease and its influence on early childhood development. Organised into four dedicated teams — Primary Health, Allied Health, Ear Nose and Throat Outreach, and Administration — Deadly Ears embodies a comprehensive approach to fostering better ear health within these communities (Queensland Government n.d.d).

The Deadly Ears Program data have shown improved ear and hearing health over time (AIHW 2021). The program has demonstrated effectiveness in engaging Aboriginal communities, with the rate of children in the critical 0-4 age group attending clinic and accessing audiology increasing from 53 per cent in 2014 to 94 per cent in 2018. The program employs Indigenous staff and reports a 98 per cent positive rating in answer to ‘Did we treat you well?’ (Queensland Government 2023). Further, Deadly Ears successfully led the push to develop a national KPI for middle ear disease and conductive hearing loss in First Nations children. The program leads the implementation of the ‘Deadly Kids, Deadly Futures’ framework (discussed above), which has ‘driven substantial state-wide changes to key aspects of the health, early childhood development and education sectors’ (Queensland Government 2023:n.p.).

Australian Nurse-Family Partnership Program

The Australian Nurse-Family Partnership Program (ANFPP) is a nurse-led home visiting initiative based on the US Nurse-Family Partnership. The evidence-based program provides support and guidance to first-time Indigenous mothers, or those with Aboriginal or Torres Strait Islander partners, in achieving personal goals and nurturing strong, healthy families. The program is funded by the Federal Government as part of the Closing the Gap Strategy and is managed by the Commonwealth Department of Health. It is delivered by 14 partner organisations, operating across 15 sites, the majority of which are Aboriginal Community Controlled Health Organisations (ACCHOs). The program involves specially trained Nurse Home Visitors (NHVs) and Family Partnership Workers (FPWs) regularly visiting expectant mothers from early pregnancy through to a child’s second birthday, providing information and education to mothers using a strengths-based approach. This allows new mothers to grow in confidence, knowledge and skills, fostering a healthy start for their babies. The home visiting teams have a deep understanding of community and individual challenges, tackling underlying issues by using an holistic and context-sensitive approach. In particular, FPWs ‘provide cultural knowledge, expertise, skills and promote understanding of the health beliefs and practices of Aboriginal and Torres Strait Islander people’ (ANFPP n.d.). The program has reported numerous success stories over more than a decade of implementation, achieving higher breastfeeding rates than national averages for Indigenous children in all remote areas and consistently meeting immunisation targets.

A recent study explores how the ANFPP contributes to the development of First Nations women’s self-efficacy. The authors found that ‘when the program facilitates the development of culturally safe relationships with staff and peers, it enables behaviour change, skill development, personal goal setting and achievement, leading to self-efficacy’ (Massi et al. 2023). Notably, the study highlights that self-efficacy theory does not encompass the broader significance of relational and collectivist ways of knowing, being and doing in the First Nations context. Although the study shows a positive impact on the development of self-efficacy, it emphasises that the broader First Nations concept of self-determination, encompassing connection to culture and community, may better describe the impact of the ANFPP on women in this study. Key takeaways from the study include the importance of strong relationships and continuity of care, First Nations staff, connection to culture and identity, and peer support and role modelling. This study demonstrates the value of community- and strengths-based approaches in fostering positive maternal and child health outcomes within Indigenous communities.

Parenting Services

Family Preservation and Reunification Response

The Victorian Department of Families, Fairness and Housing’s Family Preservation and Reunification Response (The Response) was created to align with the Victorian Government's overarching objective of enabling children and young individuals to achieve their utmost potential while also promoting the advancement of Aboriginal self-determination (Arabena et al. 2023). The aim of the Response program is to build strong families, with children who are safe, healthy, resilient and thriving, and parents and other caregivers who are supported to create a safe and nurturing home environment’ (CERE as cited in Arabena 2023). To achieve this, the Response provides flexible and intensive support for families as well as sustained support and transitions to other services.

In particular, the Response focuses on a parent coaching model as opposed to a crisis or case-management approach, seeking to empower caregivers to sustainably respond to the needs of their children. For example, one strategy included within the reunification component of the response was attendance at parenting classes, with practitioners reporting that parents who attended were more likely to experience positive outcomes (Arabena 2023). During Karabena Consulting Trust’s qualitative evaluation of the Response, it was evident that this approach led to positive relationships between caregivers and practitioners. Clients who participated in the evaluation especially praised the non-judgemental service delivery of Response practitioners, and communicated that their relationship was a partnership rather than hierarchical. Through this coaching model clients reported feeling more confident to look after their infants and to cope with stressful situations, with one noting ‘I feel more confident in responding to my baby’s needs. Before, I wasn’t sure why my baby was crying, but now I can tell when they’re hungry or tired and respond appropriately by feeding or putting them to sleep’ (Arabena 2023:53). Overall, the clients who participated in the evaluation overwhelmingly reported that the Response positively impacted the health and happiness of both parents and children.

Reflecting on a successful parenting strategy such as the Response, therefore, the Framework has the opportunity to encompass strengths-based parenting services in line with holistic ethos. Through including parent coaching strategies and initiatives founded on equal partnerships between clients and practitioners, the Framework can further empower parents to support the needs of their children.

Based on the review of academic literature, state-level initiatives and priorities, and national and international initiatives and priorities, the following recommendations are proposed:

The development of a Victorian Aboriginal Early Years Health Framework and the subsequent provision of services should be founded on the principle of self-determination. The Aboriginal-led participation and design process of the Framework accommodates Treaty principles, but it is critical that this extends beyond the development phase to both the implementation and evaluation phase.

The collection of qualitative and quantitative data that informs the development, implementation, and evaluation of the Framework should be grounded in Indigenous research methodology. Where possible, ensuring that Aboriginal and Torres Strait Islander peoples lead the collection of data during these phases is crucial.

Given the Victorian Government is committed to the Closing the Gap National Agreement, the Victorian Aboriginal Early Years Health Framework is obligated to achieve the targets set out in the Implementation Plan. Therefore, the design and implementation of the Framework must be guided by methodologies and priorities in these, and other, national documents and initiatives.

Cultural safety in early years health services is proven to increase accessibility for Aboriginal and Torres Strait Islander peoples, as well as Indigenous peoples in International contexts. Of course, Aboriginal-led early years services must be prioritised within the Framework; however, where mainstream services are a point of contact for Aboriginal and Torres Strait children and families, cultural competency should be embedded. The Framework, therefore, should include cultural competency measures and indicators.

Successful early years health programs for Indigenous peoples nationally and internationally involve local communities in the design process. Therefore, where possible, local Victorian Aboriginal communities should participate in not only the co-designing process of the Framework itself, but also in the subsequent design of localised services. This will further ensure the provision of culturally safe and responsive services.

Additionally, successful early years health programs for Indigenous peoples nationally and internationally involve local communities in the implementation process. Therefore, in addition to co-designing localised services and programs, where possible local Victorian Aboriginal communities should be provided capacity to participate in the delivery of programs.

Through a holistic approach, the Framework must take proactive measures to account for the social determinants of health for Aboriginal and Torres Strait Islander peoples, and the underlying reasons for inequities in health outcomes compared to non-Indigenous children.

In particular, the services included within the scope of the Framework should focus on prevention and early intervention to optimise health outcomes, and respond to the social determinants of health.

National and International studies demonstrate that the wellbeing of parents has a direct impact on the wellbeing of children. Therefore, parenting services and other early years health services within the scope of the Framework should adopt a strengths-based approach, where parents are coached through an aspirational perspective as opposed to case-managed through a deficit lens.

Where there is a lack of connection and communication between related early years health services, children and families are less likely to access and therefore receive necessary health care. Therefore, where possible the Framework should consider ways to remove barriers between early years services, and establish a method that enhances coordination to improve accessibility.

Despite the fact that the Framework is a Victorian Department of Health initiative, it is important to consider the recommendations from national and international literature that suggest limiting or removing funding silos to increase the likelihood that service delivery is holistic and integrated.

AHRC (Australian Human Rights Commission) 2015. The Social Justice and Native Title Report 2015, ARHC, Sydney.

Allan, L., Hatala, A., Ijaz, S., Courchene, D., Bushie, B. 2020, Indigenous-led health care partnerships in Canada. Canadian Medical Association Journal 192(9):E208-E216. doi: 10.1503/cmaj.190728

Aly, A. & McCarthy, M. 2023, Ensuring First Nations children are school ready, media release, 4 August, Ministers’ Media Centre, Ministers of the Education Portfolio, Canberra. Accessed 30 August 2023 at: https://ministers.education.gov.au/aly/ensuring-first-nations-children-are-school-ready-0.

Australian Government 2019, National Action Plan for the Health of Children and Young People 2020-2030, Department of Health, Australian Government, Canberra. Accessed 22 August 2023 at: https://www.health.gov.au/resources/publications/national-action-plan-for-the-health-of-children-and-young-people-2020-2030?language=en.

Australian Government 2023, The Early Years Strategy: Discussion Paper February 2023, Department of Social Services, Australian Government, Canberra. Accessed 22 August 2023 at: https://engage.dss.gov.au/early-years-strategy/.

Australian Government 2019, National Immunisation Strategy for Australia 2019 to 2024, Department of Health and Aged Care, Australian Government, Canberra. Accessed 22 August 2023 at: https://www.health.gov.au/resources/publications/national-immunisation-strategy-for-australia-2019-to-2024

Australian Government n.d., Connected Beginnings, Department of Education, Australian Government, Canberra. Accessed 24 August 2023 at: https://www.education.gov.au/early-childhood/community-child-care-fund/connected-beginnings.

Australian Institute of Health and Welfare (AIHW) 2020, Australia’s children, Cat. no. CWS 69, AIHW, Canberra. Available at: https://www.aihw.gov.au/reports/children-youth/australias-children/contents/executive-summary.

Australian Nurse-Family Partnership Program (ANFPP) n.d., Program Successes, ANFPP, Brisbane. Accessed on 22 August 2023 at: www.anfpp.com.au/program-successes.

Arabena, K., Onademuren, J., Reid, D. 2023, Family Preservation and Reunification Response Phase 2: Evaluation Report. Centre for Evaluation and Research Evidence, Melbourne, Victoria.

Banovcinova, Andrea & Mydlikova, E. & Vodicková, M. 2018, Parenting in low-income families from the perspective of social work. SHS Web of Conferences. 40(03010). doi: 10.1051/shsconf/20184003010

Biles B, Biles J, Friere K, Deravin L, Lawrence J, Yashadhana A. 2022, Appraising community driven health research with Aboriginal and Torres Strait Islander communities: a scoping review using the Aboriginal and Torres Strait Islander Quality Appraisal Tool. Health Promot Int. 37(5):daac077. doi: 10.1093/heapro/daac077

Bliznashka, L., Udo, I. E., Sudfeld, C. R., Fawzi, W. W., & Yousafzai, A. K. 2021, Associations between women's empowerment and child development, growth, and nurturing care practices in sub-Saharan Africa: A cross-sectional analysis of demographic and health survey data. PLoS medicine, 18(9), e1003781. https://doi.org/10.1371/journal.pmed.1003781

Bull C., Howie P., Callander EJ. 2022, Inequities in vulnerable children’s access to health services in Australia, BMJ Global Health 2022;7:e007961. doi:10.1136/ bmjgh-2021-007961

Burger, M., Einspieler, C., Unger, M., & Niehaus, D. 2022, Prioritising maternal mental health and infant neurodevelopment research in Africa - A call for action amidst the backdrop of the COVID-19 pandemic. The South African journal of psychiatry, 28:a1716. https://doi.org/10.4102/sajpsychiatry.v28i0.1716

Burton, J., Lewis, P., Lau, J., Stacey, C., Sydenham, E., Smith, F. et al. 2017, The Family Matters Report 2017: Measuring trends to turn the tide on the over-representation of Aboriginal and Torres Strait Islander children in out-of-home care in Australia. SNAICC, Melbourne, Victoria. Accessed on August 22 at: www.familymatters.org.au/wp-content/uploads/2017/11/Family-Matters-Report-2017.pdf.

Canavan, C.R., D’cruze, T., Kennedy, M.A. et al. 2022, Missed opportunities to improve food security for pregnant people: a qualitative study of prenatal care settings in Northern New England during the COVID-19 pandemic. BMC Nutrition, 8(8). doi: https://doi.org/10.1186/s40795-022-00499-7

Chamberlain, C., Gray, P., Herrman, H., Mensah, F., Andrews, S., Krakouer, J., et al. 2022, Community views on ‘Can perinatal services safely identify Aboriginal and Torres Strait Islander parents experiencing complex trauma?’, Child Abuse Review, 32(1):e2760. doi: https://doi.org/10.1002/car.2760

Chung, A., Hall, A., Brown, V., Kuswara, K., Howse, E., Stickney, B., et al. 2022, The first 2000 days: Synthesis of knowledge from the Australian Prevention Partnership Centre and CERI. Sydney, Australia: The Australian Prevention Partnership Centre.

Commonwealth of Australia, 2023, Commonwealth Closing the Gap Implementation Plan 2023.

Department of Education and Training (DET), 2017, Marrung: Aboriginal Education Plan 2016-2026, State of Victoria, Melbourne, Victoria.

Department of Health (DH), 2018, Victorian Maternal, Child and Family Health Service Guidelines, State of Victoria, Melbourne, Victoria.

Doherty, T., Engebretsen, IMS., Tylleskär, T., Burgoine, K., Bauerug, A., et al. 2022, Questioning the ethics of international research on formula milk supplementation in low-income African countries, BMJ Global Health; 7(9):e009181. doi: 10.1136/bmjgh-2022-010227

Dossetor, P. J., Freeman, J. M., Thorburn, K., Oscar, J., Carter, M., Jeffery, H. E., et al. 2023, Health services for aboriginal and Torres Strait Islander children in remote Australia: A scoping review. PLOS Global Public Health, 3(2):e0001140. doi: https://doi.org/10.1371/journal.pgph.0001140

First Nations National Constitutional Convention & Central Land Council (Australia), issuing body 2017, Uluru : statement from the heart, Accessed August 22, 2023 at: http://nla.gov.au/nla.obj-484035616 Fitzgerald, E., Hor, K., & Drake, A. J. 2020, Maternal influences on foetal brain development: The role of nutrition, infection and stress, and the potential for intergenerational consequences. Early Human Development, 150:105190. doi: https://doi.org/10.1016/j.earlhumdev.2020.105190

Gebremichael, B., Beletew Abate, B., & Tesfaye, T. 2021, Mothers had inadequate knowledge towards key essential nutrition action messages in mainly rural Northeast Ethiopia. Journal of Nutritional Science, 10:e19. doi: https://doi.org/10.1017/jns.2021.10

Gilbert, S., Irvine, R., D'or, M., Adam, M. T. P., Collins, C. E., Marriott, R., et al. 2023, Indigenous Women and Their Nutrition During Pregnancy (the Mums and Bubs Deadly Diets Project: Protocol for a Co-designed Health Resource Development Study. JMIR Publications, 12:e45983. doi: https://doi.org/10.2196/45983

Goodhue, R., Dakin, P., Noble, K. 2021, What’s in the Nest? Exploring Australia’s Wellbeing Framework for Children and Young People. ARACY, Canberra.

Government of Western Australia 2015, WA Aboriginal Health and Wellbeing Framework 2015-2030, Department of Health, Government of Western Australia, Perth. Accessed 27 August 2023 at: https://www.health.wa.gov.au/Improving-WA-Health/About-Aboriginal-Health/WA-Aboriginal-Health-and-Wellbeing-Framework-2015-2030.

Health New Zealand 2023, Kahu Taurima. Kahu Taurima | Maternity and Early Years, Te Kawanatangu o Aotearoa New Zealand Government. Accessed August 29, 2023 at: https://www.tewhatuora.govt.nz/for-the-health-sector/maternity/kahu-taurima/#about-kahu-taurima

Haora, P., Roe, Y., Hickey, S, Gao, Y., Nelson, C., Allen, J. et al. 2023, Developing and evaluating Birthing on Country services for First Nations Australians: the Building On Our Strengths (BOOSt) prospective mixed methods birth cohort study protocol, 23(1):77. doi: 10.1186/s12884-022-05277-8

Hyde, A., Verstraeten, B. S. E., Olson, J. K., King, S., Brémault-Phillips, S., & Olson, D. M. 2021, The Fort McMurray Mommy Baby Study: A Protocol to Reduce Maternal Stress Due to the 2016 Fort McMurray Wood Buffalo, Alberta, Canada Wildfire. Frontiers in Public Health, 9:601375. doi: https://doi.org/10.3389/fpubh.2021.601375

Keating, C., Wositzky, K., Prent, J., Aston, R. & Smith, H. 2016, Evaluation of Aboriginal Health Case Management and Care Coordination Models in Victoria, Effective Change, Department of Health and Human Services, Victorian Government, Melbourne. Accessed 29 August 2023 at: https://www.researchgate.net/publication/321996418_Evaluation_of_Aboriginal_Health_Case_Manage ment_and_Care_Coordination_Models_in_Victoria?channel=doi&linkId=5a3c9c40a6fdcc21d8781bbf&s howFulltext=true.

Kennedy, A., Sehgal, A., Szabo, J., McGowan, K., Lindstrom, G., Roach, P., et al. 2022, Indigenous strengths-based approaches to healthcare and health professions education – Recognising the value of Elders’ teachings. Health Education Journal, 81(4):423–438. doi: https://doi.org/10.1177/00178969221088921 Kildea, S., Gao, Y., Hickey, S., Nelson, C., Kruske, S., Carson, A., et al. 2021, Effect of a Birthing on Country service redesign on maternal and neonatal health outcomes for First Nations Australians: a prospective, non-randomised, interventional trial, The Lancet Global Health, 9(5): e651-e659. doi: https://doi.org/10.1016/S2214-109X(21)00061-9

Kral, I., et al. (2021). A strong start for every Indigenous child, OECD Education Working Papers, 251, OECD Publishing, Paris. doi: https://doi.org/10.1787/ebcc34a6-en.

Lee, A., & Ride, K. 2018, Review of nutrition among Aboriginal and Torres Strait Islander people, Australian Indigenous Health Bulletin, 18(1), Accessed August 22 2023 at: http://healthbulletin.org.au/articles/review-of-nutrition-among-aboriginal-and-torres-strait-islander-people

Liddle, C., Gray, P., Burton, J., Prideaux, C., Solomon, S., Cackett, J., et al. 2021. The Family Matters Report 2021. SNAICC, Accessed 22 August 2023 at: https://www.familymatters.org.au/the-family-matters-report-2021/

Love, P., Laws, R., Adam, M., Esdaile, E., & Campbell, K. J. 2022, A call for joined-up action to promote nutrition across the first 2000 days of life using a food systems approach. Public Health Research & Practice, 32(3):3232226. doi: https://doi.org/10.17061/phrp3232226

Lowitja Institute 2022, Community-Led Co-Design of Evaluation: A Tool to Support Culturally Safe Evaluation-Guidelines for Use; Lowitja Institute: Melbourne, Australia.

Maher BL, Guthrie J, Sturgiss EA, et al. 2021, Defining collective capability in Australian evaluations that are conducted by, for and with Indigenous peoples for health programmes, policies and services: a concept analysis protocol, BMJ Open 2021, 11:e055304. doi: 10.1136/bmjopen-2021-055304

Massi, L., Hickey, S., Maidment, S. J., Roe, Y., Kildea, S. & Kruske, S. 2023, "This has changed me to be a better mum": A qualitative study exploring how the Australian Nurse-Family Partnership Program contributes to the development of First Nations women's self-efficacy, Women and Birth, 36(6):e613-e622. doi: https://doi.org/10.1016/j.wombi.2023.05.010

McLachlan, H. L., Newton, M., McLardie-Hore, F. E., McCalman, P., Jackomos, M., Bundle, G. et al. 2022, Translating evidence into practice: Implementing culturally safe continuity of midwifery care for First Nations women in three maternity services in Victoria, Australia, eClinicalMedicine, 47:1–13. doi: https://doi.org/10.1016/j.eclinm.2022.101415

Meulewaeter, F., De Pauw, S. S. W., & Vanderplasschen, W. 2019, Mothering, Substance Use Disorders and Intergenerational Trauma Transmission: An Attachment-Based Perspective. Frontiers in Psychiatry, 10:728. doi: https://doi.org/10.3389/fpsyt.2019.00728

International Confederation of Midwives 2023, Midwifery Led Care, the First Choice for All Women, The Hague, Netherlands. Accessed 22 August 2023 at: https://internationalmidwives.org/resources/midwifery-led-care-the-first-choice-for-all-women/

Ministry of Health 2022, Interim Government Policy Statement on Health 2022-2024, New Zealand Ministry of Health, Wellington, Aotearoa New Zealand.

Mitchell, F., Walker, T., Hill, K. et al. Factors influencing infant feeding for Aboriginal and Torres Strait Islander women and their families: a systematic review of qualitative evidence. BMC Public Health 23:297. doi: https://doi.org/10.1186/s12889-022-14709-1

Morris, N. F., Stewart, S., Riley, M. D., & Maguire, G. P. 2016, The Indigenous Australian Malnutrition Project: the burden and impact of malnutrition in Aboriginal Australian and Torres Strait Islander hospital inpatients, and validation of a malnutrition screening tool for use in hospitals-study rationale and protocol. SpringerPlus, 5(1):1296. doi: https://doi.org/10.1186/s40064-016-2943-5

Musgrave, L., Homer, C., & Gordon, A. 2023, Knowledge, attitudes and behaviours surrounding preconception and pregnancy health: an Australian cross-sectional survey. BMJ Open, 13(1):e065055. doi: https://doi.org/10.1136/bmjopen-2022-065055

Nasir, B. F., Ryan, E. G., Black, E. B., Kisely, S., Gill, N. S., Beccaria, G., et al. 2021, The risk of common mental disorders in Indigenous Australians experiencing traumatic life events. BJPsych Open, 8(1):e8. doi: https://doi.org/10.1192/bjo.2021.1063

National Indigenous Australians Agency 2022, Early Years Strategy, Australian Government, Canberra. Accessed 22 August 2023 at: https://www.niaa.gov.au/indigenous-affairs/closing-gap/implementation-measures/early-years-strategy

Northern Territory Government 2018, Starting early for a better future: Early Childhood Development in the Northern Territory 2018–2028, Northern Territory Government, Darwin. Accessed 27 August 2023 at: https://cmc.nt.gov.au/__data/assets/pdf_file/0004/815386/starting-early-for-a-better-future.pdf.

Office of Audit and Evaluation 2017, Evaluation of the Aboriginal Head Start in Urban and Northern Communities Program 2011-2012 to 2015-2016. Health Canada and the Public Health Agency of Canada, Ottawa. Accessed 22 August 2023 at: Evaluation of the Aboriginal Head Start in Urban and Northern Communities Program 2011-2012 to 2015-2016 - Canada.ca

Queensland Government 2020, By Mob, For Mob: Waijungbah Jarjums Evaluation Report September 2020, Queensland Health, Queensland Government, Brisbane. Accessed 25 August 2023 at: https://clinicalexcellence.qld.gov.au/showcase/documentaries/stories/waijungbah-jarjums.html.

Queensland Government n.d.a., Deadly Kids, Deadly Futures: Queensland’s Aboriginal and Torres Strait Islander Child Ear and Hearing Health Framework 2016-2026, Department of Education and Training & Queensland Health, Queensland Government, Brisbane. Accessed 25 August 2023 at: https://www.childrens.health.qld.gov.au/chq/our-services/community-health-services/deadly-ears/deadly-kids-deadly-futures/#:~:text=Deadly%20Kids%2C%20Deadly%20Futures%20is,caused%20by%20middle%20ear%20di sease.

Queensland Government n.d.b., Clinical Excellence Stories: Waijungbah Jarjums, Clinical Excellence Queensland, Queensland Government, Brisbane. Accessed 25 August 2023 at: https://clinicalexcellence.qld.gov.au/showcase/documentaries/stories/waijungbah-jarjums.html.

Queensland Government n.d.c., Mums and bubs, Gold Coast Health, Queensland Government, Brisbane. Accessed 25 August 2023 at: https://www.goldcoast.health.qld.gov.au/aboriginal-and-torres-strait-islander-service/services/mums-and-bubs.

Queensland Government n.d.d., Deadly Ears, Children’s Health Queensland Hospital and Health Service, Queensland Government, Brisbane. Accessed 24 August 2023 at: www.childrens.health.qld.gov.au/chq/our-services/community-health-services/deadly-ears/.

Queensland Government 2023, Early Years Plan: A Great Start for all Queensland Children, Queensland Government, Brisbane. Accessed 23 August 2023 at: https://alt-qed.qed.qld.gov.au/programs-initiatives/education/early-years-plan

Rayment-Jones, H., Dalrymple, K., Harris, J., Harden, A., Parslow, E., Georgi, T., et al. Project20: Does continuity of care and community-based antenatal care improve maternal and neonatal birth outcomes for women with social risk factors? A prospective, observational study, PLoS One, 16(5):e0250947. doi: 10.1371/journal.pone.0250947

Richards, D., & Foale, A. 2011, Indigenous health: Partnership for cultural safety..., The Australian Nursing Journal: ANJ, 19(5):40–41. Accessed 23 August 2023 at: Indigenous health: Partnership for cultural safety... | The Australian Nursing Journal: ANJ (informit.org)

Safer Care Victoria 2020, Perinatal Services Guidelines, State of Victoria, Melbourne, Victoria. Accessed 23 August 2023 at: Clinical guidance | Safer Care Victoria

Santiago, P. H. R., Soares, G., Smithers, L. G., Roberts, R. M., & Jamieson, L., 2022. Psychological Network of Stress, Coping and Social Support in an Aboriginal Population, International Journal of Environmental Research and Public Health, 19(22):15104. doi: https://doi.org/10.3390/ijerph192215104

Simoncic, V., Hamann, V., Huber, L., Deruelle, P., Sananes, N., Enaux, C., et al. 2022, Study protocol to explore the social effects of environmental exposure and lifestyle behaviours on pregnancy outcome: an overview of cohort of pregnant women study. BMJ open, 12(9):e058883. doi: https://doi.org/10.1136/bmjopen-2021-058883

The Royal Women's Hospital n.d., Baggarrook midwifery care, The Royal Women’s Hospital, Parkville, Victoria. Accessed 25 August 2023 at: www.thewomens.org.au/patients-visitors/clinics-and-services/pregnancy-birth/pregnancy-care-options/baggarrook-midwifery-care.

The RACP Indigenous Child Health Working Group 2020, Indigenous child health in Australia and Aotearoa New Zealand, December 2020. The Royal Australasian College of Physicians, Sydney and Wellington.

The Southern Initiative 2017, Early Years Challenge Supporting parents to give tamariki a great start in life Summary report. The Southern Initiative and Co-Design Lab, South Auckland.

United Nations Children’s Fund (UNICEF) 2017, Early Moments Matter for Every Child, United Nations, New York. Accessed 22 August 2023 at: https://www.unicef.org/early-moments

United Nations Department of Economic and Social Affairs (UNDESA) 2022, Sustainable Development Goals Report 2022, United Nations, New York. Accessed 22 August 2023 at: The Sustainable Development Goals Report 2022 | DESA Publications (un.org) United Nations Department of Economic and Social Affairs (UNDESA) 2015, Transforming our world: The 2030 Agenda for Sustainable Development, United Nations, New York. Accessed 22 August 2023 at: https://sdgs.un.org/2030agenda

United Nations 1989, Convention of the Rights of the Child, United Nations General Assembly, Geneva. Accessed 22 August 2023 at: https://www.ohchr.org/en/professionalinterest/pages/crc.aspx

United Nations 2007, United Nations Declaration on the Rights of Indigenous Peoples (UNDRIP), United Nations General Assembly, Geneva. Accessed 22 August 2023 at: https://humanrights.gov.au/our-work/un-declaration-rights-indigenous-peoples-1#:~:text=Indigenous%20peoples%20and%20individuals%20are,their%20indigenous%20origin%20or%2 0identity.&text=Indigenous%20peoples%20have%20the%20right%20of%20self%2Ddetermination.

Victorian Government 2016, Marrung Aboriginal Education Plan 2016–2026, Department of Education and Training, Victorian Government, Melbourne. Accessed 24 August 2023 at: https://www.vic.gov.au/marrung.

Victorian Government 2017, Korin Korin Balit-Djak: Aboriginal Health, Wellbeing and Safety Strategic Plan 2017–2027, Department of Health and Human Services, Victorian Government, Melbourne. Accessed 24 August 2023 at: https://www.dffh.vic.gov.au/publications/korin-korin-balit-djak.

Victorian Government 2018a, Victorian Aboriginal Affairs Framework 2018-2023, Department of Premier and Cabinet, Victorian Government, Melbourne. Accessed 24 August 2023 at: https://www.firstpeoplesrelations.vic.gov.au/victorian-aboriginal-affairs-framework-2018-2023.

Victorian Government 2018b, Wungurilwil Gapgapduir: Aboriginal Children and Families Agreement, Department of Health and Human Services, Victorian Government, Melbourne. Accessed 24 August 2023 at: https://www.dffh.vic.gov.au/publications/wungurilwil-gapgapduir-aboriginal-children-and-families-agreement.

Victorian Government 2020, Victorian action plan to prevent oral disease 2020–30, Department of Health and Human Services, Victorian Government, Melbourne. Accessed 25 August 2023 at: https://www.health.vic.gov.au/preventive-health/oral-health-planning.

Victorian Government 2021, Maternal and Child Health Service Guidelines, Department of Health, Victorian Government, Melbourne. Accessed 24 August 2023 at: https://www.health.vic.gov.au/maternal-child-health/maternal-and-child-health-service-framework.

Victorian Government 2023, Victorian Early Years Learning and Development Framework (VEYLDF), Department of Education and Training, Victorian Government, Melbourne. Accessed 24 August 2023 at: https://www.vic.gov.au/victorian-early-years-learning-development-framework-veyldf.

Vine, K.; Benveniste, T.; Ramanathan, S.; Longman, J.; Williams, M.; Laycock, A.; et al. 2023, Culturally Informed Australian Aboriginal and Torres Strait Islander Evaluations: A Scoping Review. Int. J. Environ. Res. Public Health, 20(14):6437. doi: 10.3390/ijerph20146437

World Health Organisation (WHO), United Nations Children’s Fund (UNICEF), World Bank Group 2018, Nurturing care for early childhood development: a framework for helping children survive and thrive to transform health and human potential, World Health Organization, Geneva.

Yoorrook Justice Commission 2022, Strategic Plan 2022-2024. Yoorrook Justice Commission, Collingwood, Victoria.

Yoorrook Justice Commission 2023, Yoorrook for justice: Report into Victoria’s child protection and criminal justice systems, Yoorrook Justice Commission, Collingwood, Victoria.

Zeanah P, Burstein K, Cartier J. 2018, Addressing Adverse Childhood Experiences: It’s All about Relationships. Societies, 8(4):115. doi: https://doi.org/10.3390/soc8040115