The poor health of Australia's Indigenous people relative to the nation's population is well documented. Indigenous people on average live 17 years less than other Australians, and suffer higher rates of nearly every type of illness and injury [1, 2]. The reasons for these disparities are complex, but undoubtedly relate to a history of colonisation and ongoing disadvantage. Australia's approximately 450,000 Indigenous people, which make up 2.4% of the population, are more likely to live in remote areas far from services, less likely to be educated or employed, more likely to be jailed, and less likely to have adequate housing .
While the well-known determinants of health inequality, such as employment, education and wealth, have been extensively studied in the Aboriginal and Torres Strait Islander population, it is only recently that the social and emotional aspects of health have received much attention. Since the 1990s it has been widely recognised in Australia that mental illness and stress are significant problems for Indigenous people, as well as direct causes, moderators and modifiers of physical ill-health [3–5].
The increase in interest in this area has been in response to the efforts of Indigenous leaders to raise the profile of mental health/Emotional and Social Wellbeing (ESWB) on the national policy agenda, through what has been called the Indigenous Mental Health Movement [:85] (Note that the term 'Emotional and Social Wellbeing' is currently the term used within Aboriginal and Torres Strait Islander health policy to represent an area that includes mental health ). It represents, in part, an attempt to recognise Indigenous definitions of health which see health holistically [:ix]. Indigenous people have expressed that ESWB is important for its own sake and have outlined some of its dimensions:
Enhancing emotional and social wellbeing involves support for healthy relationships between families, communities, land, sea and spirit...A focus on strengthening communities and culture is fundamental to empowering individuals and communities to identify and meet their own needs. Strong healthy communities are those where individuals experience a sense of belonging, trust, participation and social support [:9].
Elsewhere, Indigenous people have argued that ESWB is crucial for good physical health:
Aboriginal people emphasised the strong relationship of mental health and well-being to physical health and saw loss of mental well-being as contributing in a major way to the poor physical health and health outcomes of Aboriginal people. There is much to suggest that this is indeed a further significant and major contributor to the adverse and deteriorating state of the health of Aboriginal people [:1]
This view is congruent with models of the social determinants of health deriving from the field of social epidemiology. A prominent model sees 'upstream' factors such as housing policy and educational attainment influencing 'midstream' factors such as psychosocial factors, health behaviours and access to health care, which in turn influence 'downstream' factors, in this case physical health. Concepts of ESWB fit most clearly as psychosocial factors in this model, alongside stress, control, depression, self-esteem, coping, and anger [:436]. It is also recognised that mental health issues are responsible for a significant proportion of morbidity worldwide .
It would seem, then, that both Indigenous and Western perspectives see ESWB as critical in understanding and addressing health inequalities. The Australian Government has responded to this by developing national policies for Indigenous Emotional and Social Wellbeing and funding numerous programs including the establishment of 16 Emotional and Social Wellbeing regional centres within community-controlled Aboriginal and Torres Strait Islander health services, where Indigenous people can access free culturally-appropriate counseling [7, 12, 13].
Unfortunately, these significant policy and program innovations have not been matched by relevant, quality population research. The research effort into Indigenous concepts of ESWB and its links to mental and physical health have been hampered in part by a lack of validated scales for measuring ESWB in Indigenous populations. Below we address some reasons behind this tardiness of methodological development despite the prominence given to ESWB in Indigenous health policy.
First, the appropriateness of Western concepts for representing Indigenous concepts has been questioned. Scholars in the emerging field of Indigenous psychology argue that "psychological theories reflect the values, goals and issues of the United States of America and they are not generalisable to other societies," and that "psychological theories have been used and continue to be used as a tool for cultural dominance [:76]." In Australia, a similar discourse exists, arguing that the presumption of universality and a preoccupation with individualism are the core reasons why Western psychological concepts are inappropriate and potentially damaging to Indigenous people . The Australian Psychological Society currently advises caution with using psychological scales with Aboriginal and Torres Strait Islanders as "there are currently no known formal psychological tests that have been developed specifically for use with indigenous people and that provide current-day norms and measurement statistics for indigenous test takers [:3]." Similarly, Australia's National Health and Medical Research Council cautions researchers to take heed of the many cultural differences between Indigenous and non-Indigenous people, as well as differences between Indigenous peoples [:3]. Indigenous and non-Indigenous scholars in Canada, New Zealand and the United States have expressed similar sentiments [17–20].
To date, only one tool has been developed specifically for measuring mental health status in Australian Indigenous youth populations, and the initial validation of this tool has not yet been replicated . While this advance is to be applauded, scales to measure other aspects of ESWB are urgently required. Outside Australia, there has been further progress in the development of scales specifically for the measurement of mental health status in Indigenous people. Important examples include the Hua Oranga scale developed in New Zealand to measure mental health outcomes in Maori populations , and the Voices of Indian Teens survey developed to measure aspects of mental health and substance misuse in American Indian adolescents . The large Circles of Care program in native communities in the United States found that most communities developed their own scales to evaluate the process and quality of mental health care, while others used mainstream scales .
Second, even if it could be successfully argued that it is appropriate to apply Western psychological concepts such as stress, self-efficacy and depression to Indigenous people, there is no consensus on how these concepts could be measured in individuals and populations. It has been suggested that an in-depth psychological interview involving cultural consultants is the most appropriate way of assessing the mental health and ESWB of individual Indigenous people, and that this is the most appropriate method for research [21, 25]. As this method requires a significant commitment of time and resources, it is not usually practicable for research projects involving large numbers of people. In order to develop an understanding of ESWB within populations, rather than just individuals, scales must be available that are effective and acceptable to these populations.
This is also necessary as health researchers, increasingly interested in the links between mental and physical health, are increasingly using mainstream psychological scales in their health research projects. In other Indigenous populations, such as Native Americans in the United States, many mainstream scales have been evaluated (for example [26, 27]. More recent research can use these mainstream scales with some confidence that they are valid in the Native American context [28, 29]. In Australia, where this earlier research effort has not been replicated, the use of mainstream scales with Indigenous populations is on shakier ground. Where mainstream scales are used by health researchers in Australia, it is common that correlations of the scales with health outcomes are simply reported, without a comprehensive evaluation of the scales' performance . Health researchers are then forced to try and explain correlations they have found without knowing whether the scale effectively measured what it was intended to measure. It is important for this group of researchers that consensus be reached on a set of psychological scales that are appropriate and valid for use in Australian Indigenous populations.
Some Australian health researchers have taken heed of these warnings and developed novel scales for a particular Indigenous community [31–33]. Often, the resourcing of the project and/or the methodology mean the scale is not adequately evaluated. In other cases, the results are not published in journals and are thus difficult to access. Westerman argues that in this area of research, the belief that " 'what works for one Aboriginal group will not be valid for another'...is perhaps the greatest obstacle to the provision of conceptually and empirically sound research in this area of enquiry" .
Thus there are two poles of opinion regarding the use of Western scales with Indigenous populations: one using mainstream scales; and the other, developing new scales for each community. Both extremes contribute to the lack of sound published data, and the resulting lack of consensus among the research community on valid scales for measuring ESWB across Indigenous populations. The lack of quality published data also means that researchers cannot draw on the work of others, perpetuating a cycle of over-research and potentially poor quality research.
The research community has a responsibility to ensure that health inequalities are addressed in a manner acceptable to Indigenous people, and that Indigenous people are not exposed to poor quality research or over-researched. In order to fulfill those responsibilities, it is imperative that the Australian research community attempt to generate some consensus about the best scales to use to measure ESWB, so that the body of evidence in this area increases, and the chance of Indigenous people benefiting from their participation in research is maximized.
This paper attempts to take a step toward consensus on scales for measuring ESWB by reporting on the use of a Negative Life Events Scale (henceforth NLES) to measure stress in two samples of Indigenous Australians. We also outline the basic methodological principles for establishing the validity of scales, intended to provide guidance for health researchers who wish to evaluate scales used in their research.