Overall, the physical health of Indigenous men is among the worst in Australia, and very poor in comparison to other first nations [1
]. Recent reports from the Australian Bureau of Statistics [3
] have indicated that the life expectancy for Indigenous Australian men is 11.5 years lower than that of non-Indigenous men. Further, their mortality rates are at least two times higher than that of non-Indigenous Australians, and at least four to five times higher in young adult and middle-aged groups [3
]. The most significant conditions contributing to the burden of disease amongst Indigenous Australian men are cardiovascular disease, chronic respiratory disease, diabetes, and obesity [4
]. This adversity is also reflected in their poor mental health [1
] and negative body esteem [6
A major factor contributing to Indigenous Australian's physical and emotional health is the significant lifestyle changes that have taken place since colonisation [9
]. These include an adoption of "Westernized" diets, increased consumption of foods high in fat, sugar and salt, and a decline of physical activity. This is a marked contrast to the Indigenous lifestyle before European colonisation where Aboriginal people "gathered, trapped and hunted indigenous foods that were predominantly low in dietary energy, fat, salt and sugar, and high in fibre and complex carbohydrates. They also expended considerable physical energy in obtaining sufficient water and food to survive" [[9
], p. 16]. Indeed, two of the major contributors to the current condition of Indigenous Australians health are poor nutrition [10
] and sedentary behaviour [12
]. For example, findings from the Heart Health Project have indicated that that Indigenous Australians are not eating fruit and vegetables or exercising at levels recommended in the dietary guidelines for Australians [13
]. Other studies have also indicated that the main risk factors contributing to the disease burden of Indigenous Australians, and the pronounced health gap between Indigenous and non-Indigenous Australians [14
] are modifiable factors including physical inactivity, high blood cholesterol, and low fruit and vegetable intake [15
Another significant factor to consider is that many Aboriginal people have had and continue to have little or no control over their circumstances. As argued by Palmer [[16
], p. 23]: "It's hard when people push you in all sorts of different directions; one group wants you to modernise, the other wants you to stay traditional. What do Central Australian Aboriginal men want? This is what our people should be thinking about-not what others think is best for us! ... Aboriginal men need to have a purpose in daily life and our culture; it is both our Tjurunga1
and family that really matter. As Aboriginal men we are supposed to uphold the lore and take care of Tjurunga and family, then pass that knowledge to our sons. As men maybe then we will have a purpose again and make us stronger in men's lore."
The above discussion presents some of the risk factors that may contribute to the poor physical and mental health of Indigenous men. It also suggests that there may be protective factors that can be targeted to enhance their health. Despite the frequent recognition that sociocultural factors may play a crucial role in health outcomes for Indigenous Australians, these are often not examined because they are very difficult to measure [17
]. To assist in developing and implementing more effective health change strategies an improved understanding of these factors is necessary. An array of these factors, either identified by previous research or raised through broader discourse around the health of Australia's Indigenous peoples, will now be considered.
Indigenous men's understanding and value placed on health
Indigenous Australians do not place importance on their health in the same way as non-Indigenous Australians. In fact, many traditional Indigenous concepts of health are incongruent with Western views and those represented in current models of health psychology and allied disciplines that are used to develop health programs for Indigenous people [19
]. As argued by Anderson [23
], Indigenous people do not make the Platonic and Cartesian divide between mental and physical being; instead "health includes the physical, social, emotional, cultural and spiritual wellbeing ... and this is not only of the individual but of the whole community" [[24
], p. 68]. McCoy [[25
], p. 220] also points out that in some communities a "person is healthy (or playa)
when their body (yarnangu)
is in a right relationship with their inner spirit (kurrun
) and with others (walytja
)". Therefore, we need to better understand and incorporate these views in any new health initiatives [23
Fitness, health and body image
Similarly, Aboriginal men's criteria for physical esteem and their views of an ideal body are often far removed from the fit, lean and muscular male body epitomized in the Western media [26
]. McDonald [21
] has argued that "for indigenous people who have lived through periods of feast and famine, thin bodies were not valued". Moreover, many Indigenous people are of the view that "the ability to put on weight during good seasons enabled people to survive the bad seasons"; "thinness can indicate weakness, excessive worry, or ill-health"; and a skinny body is viewed as "sexually unattractive" [[21
], p. 88].
In stark contrast to these traditional views, many men from non-Western cultural groups [27
], including Indigenous Australian men [6
], are increasingly exposed to media representations of muscular, lean, athletic, and strong bodies. We do not know how many men are adopting these images as their ideal standard, comparing themselves with this standard, and then feeling that they do not measure up. However, we do know that the body image, self-esteem and other self-concepts of Indigenous men are very negative and they are more negative than those of European men [7
]. Moreover, an increasing number of Indigenous Australian men are either severely underweight or overweight [25
]. The problem of being underweight is significant for a large number of young men who sniff petrol [31
]; petrol sniffing is used by young men "to achieve power over their bodies" and then "their thin bodies symbolise their marginalised place" [[25
], p. 164]. On the other hand, the increasing rates of obesity among Indigenous men is another significant problem, and in part attributable to the adoption of the unhealthy "Westernized" lifestyles, as discussed above [9
]. Therefore, a better understanding of how Indigenous men view and care for their bodies is critical for them to improve their health and wellbeing.
One key sociocultural variable to consider is acculturation. Acculturation refers to changes in identity, attitudes, values, and behaviours that accompany an individual's movement from their original or 'heritage' culture towards a new and different mainstream culture [33
]. In most research into acculturation, the focus is on how immigrant groups adapt to their host country's cultural ways [34
]. In the case of colonized first nation's peoples it can be used to refer to how these groups have adapted to an imposed superculture. Acculturation has been shown to be important in the development of physical and emotional health among other cultural groups [35
]. However, to the authors' knowledge, no study has specifically examined the effects of acculturation on Indigenous Australian men's physical and emotional health. Although diverse characteristics of an individual are thought to be affected by acculturation (all acculturation measures assess cultural identification across numerous life domains, i.e. family, relationships, leisure, work and body image), the process of acculturation is typically conceptualized and measured as a coherent and uniform shift in all these characteristics (identification responses are combined across domains). We doubt, however, that acculturation operates in such a uniform manner. Certainly, cultural shifts in particular characteristics and within particular domains are likely to be more relevant to Indigenous men's health risk behaviours than others. Therefore, it is important to consider these different domains.
Acculturation can be measured both unidimensionally and bidimensionally. Unidimensional models of acculturation suggest that movement towards a mainstream culture necessitates the disappearance of distinctive values or perspectives related to heritage culture [36
]. Alternatively, bidimensional models conceive acculturation as a process in which identification with the mainstream culture and the heritage culture are free to vary independently [37
]. Given the complex and dynamic nature of Aboriginal men's cross-cultural experiences, and the challenges to Indigenous cultures that have occurred in Australia, it appears necessary to adopt a bidimensional view of acculturation and consider identification with traditional culture separately from the imposed Western culture. This will enable the determination of whether a closer identification with traditional culture is a protective factor for Indigenous men, as has been found in previous research with other (immigrant) cultural groups [38
]. Given the changes brought about by the adoption of 'Westernized' lifestyles, it may also be that a closer identification with the dominant mainstream culture is associated with a more negative body image and more unhealthy patterns of eating and exercise. However, this hypothesis awaits further investigation.
Loss of traditional roles
In addition to acculturation, another crucial factor to consider is the loss of traditional masculine roles that have resulted from colonization. This change has been well documented in the literature, and is often attributed to the breakdown of the kinship system and its related social rules as a result of interference in families and communities by the state and churches [40
]. Currently, Indigenous men are viewed as fearful, confused, ashamed, angry, and lost [[41
], p. 3]. These are "not qualities we could describe as ideally male or masculine" [[41
], p. 3]. Moreover, "Aboriginal men no longer see themselves as the warrior, providers for the families or role models in their own community" [[41
], p. 4]. Rather Indigenous men see themselves as "welfare dependents with no voice and, if suffering from mental illness no real future" [[41
], p. 4]. Similarly, Adams [[42
], p. 70] has argued that "Aboriginal men have lost the roles that generated prestige and self-esteem (or relational self-esteem); they have lost the ability to achieve and excel in an area beyond the family or household".
The loss of men's traditional masculine roles is likely for many men to contribute to a sense of helplessness and hopelessness or more specifically, a pessimistic explanatory style [43
], and this is turn may be perpetuating men's unhealthy behavioural practices: "Persons who suffer rejection, discrimination, ostracism and alienation; or shaming and hostility within their families or communities; and perceive themselves as powerless victims, are likely to become self-destructive" and this can lead to a range of "unhealthy or risky behaviours, such as poor diet and little exercise" [[45
], p. 45].
In order to counteract the loss of traditional masculine roles, it is crucial that we find ways to promote new roles that Indigenous men can value. One such means is via athleticism and sport. The sporting context is one of the main forums that Western males have for demonstrating the various aspects of masculinity that are closely aligned with the pursuit of fitness and muscularity. These include athletic strength and superiority, competitiveness, toughness, endurance, leadership, status, power, and authority [46
]. Increasingly, sport is also becoming a strong and positive influence for many Indigenous men. For example, the importance of sport in the lives of young Indigenous men has been linked to the company of peers and positive interactions with older men. For example, McCoy et al. [[25
], p. 25]: proposed "young men need older men to watch over them and 'grow them up', older men also need those opportunities to care for, protect and teach those who are younger, and in turn be cared for by younger men". Other positives associated with sports, and football in particular, include the importance of 'joining in together' [[25
], p. 174] and providing "an energetic social and geographical 'space' for exercise, discussion and male group activity." [[47
], p. 82]. Importantly too, "the skills that are needed within the (Australian Rules) football arena are very similar to those that men have developed and learned over many years as they hunted in the desert" [[25
], p. 182].
Familial and community relationships
Promoting and valuing intergenerational and interpersonal relationships is also important for men's health. As articulated by McCoy [25
], "holding" encapsulates the strong emphasis that Indigenous cultures place on intergenerational and interpersonal relationships, that is, caring and being responsible, assuming responsibility, teaching and providing company for younger people. This is clearly seen in many of the positive interactions among Indigenous men: "men travelling together; older men guiding and watching over younger men, men learning, engaging and competing in the company of other men" [[25
], p. 144]. These all provide opportunities for men to integrate "the physical, social and spiritual dimensions of health and life", and thus promote "confidence, strength and dignity" [[25
], p. 144]. A more developed understanding of ways in which these familial and community relationships influence men's health and health behaviours could improve the ability to design and implement health promotion strategies that effectively incorporate these factors, and thus represents another potential avenue of investigation.
In summary, the above discussion indicates a range of factors that may influence the health attitudes and behaviours of Indigenous men in Australia, and contribute to their poor health, or protect them from poor health. There is, however, a need for an increased understanding of these factors and how they may interact. This understanding must also necessarily be informed from the perspective of Indigenous men themselves. The remainder of this paper will describe the aims and expected outcomes, research framework, recruitment protocol, design, and data analytic techniques of a study designed to explore these factors and further develop our understanding of how to improve the health of Indigenous Australian men.
Aims and expected outcomes
The overall aim of this study is to examine factors related to eating and physical activity among young Indigenous Australian men, and their attitudes and behaviours relating to their body, diet, and physical activity. By closely working with men and the communities in which they live, their notions of health, the body, well-being, and other aspects of their "life-world" can be better understood [48
]. Given that Indigenous Australians are a highly migratory and heterogeneous community [49
], we will work with young men from urban, rural and remote locations. There also appears to be different health problems and risk factors in these contrasting environments [50
]. These different factors have yet to be evaluated systematically over varying locations and contexts, however, and it may be the case that recommendations and strategies that are effective in one setting may not work in another. Therefore, a comprehensive assessment of both risk and protective factors will be targeted over a variety of locations to advance theory development in the field.
We will aim to use the findings to identify strategic points of collaboration and action; and promote health enhancing strategies. These strategies will be developed and implemented with the Indigenous community in the collaborative manner. The expected outcome of this study is a better understanding of young Indigenous Australian men's views of health and well-being, and the sociocultural factors that contribute to their relatively poor physical and emotional health. Knowledge of these factors may then be used to develop more effective prevention strategies that promote healthy eating and positive patterns of physical activity.