Background: Children’s development is dependent on a range of factors influencing their life course outcomes. Protective and challenging social and cultural determinants impact how Indigenous families support their children’s developmental foundations. However, there is a lack of international evidence investigating Indigenous child development interventions. To gain a perspective across nations with comparable settler-colonial histories, this scoping review summarised studies on family and community-centred approaches among Indigenous populations in Australia, Canada, New Zealand, and the United States, focusing on outcomes and evidence gaps. Methods: A scoping review followed PRISMA-ScR guidelines. Medline, CINAHL, and PsycINFO (Ovid) were searched from their inception to October 2025, including grey literature sources from Aboriginal HealthInfoNet, the Lowitja Institute and the Secretariat of National Aboriginal and Islander Child Care. Empirical studies, including quantitative, mixed-methods, evaluation studies, and descriptive or case-study designs, were included provided they reported empirical data on intervention outcomes. Due to study heterogeneity, data were synthesised narratively. Results: Following screening of 2355 records, eight from 2013 to 2020 met the inclusion criteria. These were mostly small-scale, non-randomising designs evaluating different interventions, with the behavioural and emotional domain being the most frequently assessed outcome, alongside developmental vulnerability and academic/educational areas. There was limited consideration of protective cultural determinants of health in the study design and implementation. Six studies reported positive associations between interventions or programmes and early childhood development outcomes. Conclusions: While the number and rigour of identified interventions were limited, several demonstrated potential benefits for Indigenous children’s early childhood development. However, strengthening the evidence base requires culturally grounded, adequately powered evaluations using rigorous study designs that include culturally co-designed adaptations conducted with Indigenous families and communities. Support is recommended for capacity building and funding.

Summary box The population of Gaza is experiencing a health and humanitarian crisis.

Introduction: This consensus statement recommends eight high-level trackable policy actions most likely to significantly improve health and wellbeing for children and young people by 2030. These policy actions include an overarching policy action and span seven interconnected domains that need to be adequately resourced for every young person to thrive: Material basics; Valued, loved and safe; Positive sense of identity and culture; Learning and employment pathways; Healthy; Participating; and Environments and sustainable futures. Main recommendations: Provide financial support to invest in families with young children and address poverty and material deprivation in the first 2000 days of life. Establish a national investment fund to provide sustained, culturally relevant, maternal and child health and development home visiting services for the first 2000 days of life for all children facing structural disadvantage and/or adversity. Implement a dedicated funding model for Aboriginal and Torres Strait Islander community-controlled early years services across the country to ensure these services are fully resourced to provide quality early learning and integrated services grounded in culture and community. Properly fund public schools, starting by providing full and accountable Schooling Resource Standard funding for all schools, with immediate effect for schools in communities facing structural disadvantage. Establish legislation and regulation to protect children and young people aged under 18 years from the marketing of unhealthy and harmful products. Amend the electoral act to extend the compulsory voting age to 16 years. Legislate an immediate end to all new fossil fuel projects in Australia. Establish a federal Future Generations Commission with legislated powers to protect the interests of future generations. Changes in approach as a result of this statement: Together, these achievable evidence-based policies would significantly improve children and young people's health and wellbeing by 2030, build a strong foundation for future generations, and provide co-benefits for all generations and society.

The Lancet commission on culture in health1 identified positive cultural connections as key to achieving equity in health and wellbeing for all people; however, action towards culture in health has remained largely neglected. The intent of this article is not to debate any singular aspect of culture, identity, Indigeneity, or indeed Indigenous cultural identity, but to promote the application of a human rights and cultural lens across social determinant-informed policy making, to facilitate positive health impacts and nurture and maintain wellbeing. “Positive sense of identity and culture” is one of seven domains considered in the MJA supplement on the Future Healthy Countdown 2030. While culture and identity is of importance to all people, it is especially relevant to children and adolescents given it is during early life that culture and identify are formed.2 Childhood and adolescence are also where individuals are exposed to, and where they can shape, the social determinants of health.3 Moreover, in this article, we argue that positive cultural practices and a strong sense of identity are protective factors for child and adolescent wellbeing (Box 1). Currently available national indicators of cultural wellbeing are limited. Those that are available are: In its broadest sense, culture is said to be the whole complex of distinctive spiritual, material, intellectual and emotional features that characterise a society or social group. It includes not only the arts and languages but also modes of life, the fundamental rights of the human being, value systems, traditions, and beliefs. A loss of any cultural foundation is a loss to humankind.5 Importantly, culture is not static, it is fluid and adaptive, changing with time and geography and incorporating new events and exposures. In Australia, and around the world, various policies have perpetuated the systematic denial of the basic human rights of Indigenous peoples and other marginalised and vulnerable groups. These ongoing experiences of colonisation, exclusion and discrimination are critical to understanding the contemporary determinants of poor health that Aboriginal and Torres Strait Islander people (and other populations) continue to experience.6, 7 Conversely, cultural policies and culture in policies aim to protect, stimulate and enrich each people's identity and cultural heritage, and establish absolute respect for and appreciation of cultural minorities and the other cultures of the world.5 The definition of identity is a fluid, complicated and unclear concept that nonetheless plays a central role in ongoing debates.8 In very simple terms, it can be described as a sense of belonging that derives from shared origins or characteristics.9 We identify in many ways — according to gender, religion, geography, culture, hobbies, ethnicities, language groups — and how we identify, or how we attempt to build an identity for ourselves, is complex and multifaceted. For those who identify as Indigenous there are additional layers and complexities, including social and political discourse on identity and cultural belonging — the claims and counter claims, legal criteria imposed by colonisers, community gatekeepers and individuals who do not know the difference between heritage and legitimate Indigenous cultural ancestry and all of the responsibilities that come with such a privilege.10, 11 Despite the tension and confusion, there is also growing evidence to confirm that a positive sense of cultural identity is a protective factor and supports the process of resilience.12, 13 Further, identity is not only dependent upon individual status, but on community level and collective perspectives and connections. For Aboriginal and Torres Strait Islander peoples, identity is based on a cultural sense of self grounded within a collectivist perspective that views the self as inseparable from, and embedded within, family and community.14 Health and wellbeing are complex concepts and there is no clear consensus across or within cultures as to how these constructs should be defined.15, 16 In broad terms, wellbeing is a good or satisfactory condition of existence; a state characterised by health, happiness and prosperity; a positive outcome that is meaningful for people. At a minimum, it includes the presence of positive emotions and moods (eg, contentment, happiness), the absence of negative emotions (eg, depression, anxiety), satisfaction with life, fulfilment, and positive functioning (social, economic). As outlined by national reference and working groups,17, 18 there are nine guiding principles that underpin social and emotional wellbeing (Box 2); these include recognition of the centrality of kinship, cultural diversity, and Aboriginal strengths. Created by Social Health Reference Group;17 adapted from Swan and Raphael.18 Indigenous wellbeing is an inclusive concept that encompasses physical, psychological, social and cultural aspects, both individual and collective. Issues core to Indigenous wellbeing also include connection to one another and to the environment and natural world. For children and adolescents — as for all people — wellbeing is deeply impacted by the intergenerational impacts of discriminatory policies and practices, and the resultant trauma, grief, violence, diminished family and community cohesion, cultural dislocation, and socio-economic disadvantage.19 Resilience may be defined as the capacity to cope with, and bounce back after, the ongoing demands and challenges of life, and to learn from them in a positive way.20 This includes positive adaptation despite adversity, or a class of phenomena characterised by good outcomes despite serious threats to adaptation or development.21 Resilience may also be considered as adaptation over time, “a dynamic process involving an interaction between both risk and protective processes, internal and external to the individual … of varying degrees of impact, and … at varying points in development”.22 The exploration of resilience is a powerful and culturally relevant construct. Cultural resilience is the capacity of a community or cultural system to absorb disturbance and reorganise while undergoing change, in order to retain key elements of structure and identity that preserve its distinctness.8, 22, 23 Iris Heavyrunner and other educators proposed additional cultural protective factors, cultural resources for resilience — symbols and proverbs from common language and culture, traditional child rearing philosophies, religious leadership, counsellors and elders.24 We understand the social determinants of health to mean the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels.25 It is widely accepted that health inequities arise from these social, material and political circumstances in which people live, and the systems put in place to deal with ill health.26 Marmot has also observed that the health gap between Indigenous and non-Indigenous Australians “bespeaks large social inequalities”.27 However, addressing only social determinants will continue to fail Indigenous Australians. The social determinants of health are deeply situated within a deficit context. Although important in the pathway between cultural discrimination, marginalisation and poor health, a social determinants approach in isolation risks reinforcing this deficit perspective, emphasising poorer health outcomes for those from lower socio-economic populations, with lower educational attainment, long term unemployment and welfare dependency, and intergenerational disadvantage.28 Indigenous peoples the world over have long understood that positive cultural practices are protective, and can build resilience, particularly in children and young people. The United Nations and its affiliated agencies have considered culture in the context of community development, creating toolkits and indicators to measure impacts of culture on development and social outcomes,29, 30 but have not connected culture to health outcomes. The lead author of this article (NB) has been working for many years to articulate and develop a framework for the cultural determinants of health using a strengths-based approach that acknowledges that stronger connections to culture and country build stronger individual and collective identities, a greater sense of self-esteem, resilience, and improved outcomes across the social determinants of health, including education, economic stability and community cohesion. A positive sense of self, inclusive of domains across culture, spirituality, politics and social engagement, is a key factor in strengths-based approaches and positive trajectories across the life course. A growing body of evidence demonstrates that the protection and promotion of traditional knowledge, family, culture and kinship contribute to community cohesion and personal resilience.4, 11, 17 Further, cultural links and practices — for example, extended family, access to traditional land, revitalisation of traditional languages, learning dance and story, and understanding traditional roles and responsibilities — are protective factors that improve resilience against emotional and behavioural problems.31 To illustrate this approach, NB developed a conceptual framework (Box 3) reflective of the Articles of the United Nations Declaration on the Rights of Indigenous Peoples, proposing that these cultural determinants underpin social determinants.32 The original framework has been expanded to consider examples of implementation and measurement of these cultural determinants and is presented in Box 4.33 Both frameworks were presented at the United Nations Permanent Forum on Indigenous Issues. A combined social and cultural determinants approach recognises that there are multiple, complex drivers of wellbeing and ill health, many of which lie outside of the health sector, and which therefore require a collaborative, inter-sectoral approach. Indigenous perspectives and practices also hold the promise of benefiting mainstream systems and enabling positive social determinant impacts for all. Lessons learned through experience in Indigenous health and politics (nationally, regionally, globally) reinforce that Indigenous perspectives, values and practices can enrich our professions, communities and policy environments far beyond the limits of Indigenous services. What we do as Indigenous communities, parents, clinicians, educators and knowledge holders may be freely gifted if the systems and services are ready to embrace truth telling, understand the context, and honour the gift. To reinforce the message — Indigenous rights are human rights. The cultural determinants are just as relevant to culturally and linguistically diverse groups, LGBTQIA+ people, refugees and non-Indigenous communities as they are to Indigenous peoples. The guiding principles are self-determination, freedom from discrimination, freedom from assimilation, and collective rights. If we, as a nation, want our children to be physically, emotionally and psychologically healthy, to be generous, kind and resilient, to be active social and economic participants, and if we hope to mitigate their risk of vulnerability to antisocial influences or radicalisation, then we need to work harder to ensure they know that they are loved, supported, heard. Positive cultural practices are protective factors against toxic stress, health risk, mental health, and behavioural issues. The Human Development Index is a tool developed by the United Nations to measure and rank countries’ levels of social and economic development based on four criteria: life expectancy at birth; mean years of schooling; expected years of schooling; and gross national income per capita.34 A key question is whether these truly reflect and measure what is most relevant to people, including Indigenous peoples. Using economic parameters does not capture how people feel about their lives; for example, the quality of their relationships, their positive emotions and resilience, the realisation of their potential, or their overall satisfaction with life. Further, wellbeing approaches acknowledge that money is not the answer, and that macro-economic measures such as gross domestic product do not comprehensively capture or reflect what ordinary people perceive about the state of their own lives. Hence the need to develop less traditionally mainstream measures and indicators to reflect progress toward improved social and cultural determinants of health — metrics that better capture how people feel about cultural identity, cultural connections, language reclamation, and Indigenous content in mainstream curricula. This article is part of the MJA supplement on the Future Healthy Countdown 2030, which was funded by the Victorian Health Promotion Foundation (VicHealth) — a pioneer in health promotion that was established by the Parliament of Victoria as part of the Tobacco Act 1987, and an organisation that is primarily focused on promoting good health and preventing chronic disease for all. VicHealth has played a convening role in scoping and commissioning the articles contained in the supplement. No relevant disclosures. Commissioned; externally peer reviewed.

As highlighted by the recent World Health Organization–UNICEF–Lancet Commission on children wellbeing, our children face an uncertain future.1 As stated in the Commission's report, “Climate change, ecological degradation, migrating populations, conflict, pervasive inequalities, and predatory commercial practices threaten the health and future of children in every country”.1 The welfare of Australia's children, young people and future generations is certainly under threat (Box). Key indicators: What is lacking? Ensuring all children and young people have the right to clean, healthy and sustainable environments has recently been adopted within the United Nations Rights of the Child (General comment no. 26).2 “Environments and sustainable futures” is also one of the seven domains considered in the MJA supplement on the Future Healthy Countdown 2030, which aims to track key indicators of children's and young people's wellbeing and outline policy areas where change could make a real difference by 2030. Two recent reports highlighted just how badly Australia is doing and how lowly it ranks on climate and sustainability issues.1, 3 The premise here is that although high income countries may rank well on conventional statistics that favour survival and flourishing, they are doing so at the expense of compromising a sustainable future for their children. However, total country data hide significant inequalities across diverse groups and locations within the country (see below). The WHO–UNICEF–Lancet Commission created a sustainability rank based on carbon emissions exceeding 2030 targets.1 Using this method, Australia ranked 174 out of 180 countries, with excess emission of 524%. Only Qatar, Trinidad and Tobago, Kuwait, the United Arab Emirates, Bahrain and Saudi Arabia, which are all oil and gas producing nations, ranked lower.1 There are also three cross-cutting themes that will guide how to respond to this report. These illustrate interlinkages, suggesting the need for whole-of-government and whole-of-society responses; demonstrate the considerable inequalities in these environments and, therefore, the variability in children's responses (thus the causes of poverty in our nations need to be seriously addressed); and identify how powerless children are with respect to influencing policies (with good examples of how to engage young people in the solutions to improving these environments). The report was a damning indictment for most wealthy countries but particularly so for Australia. Unhealthy living conditions can irreversibly harm children's mental and physical wellbeing, their cognitive development and, hence, their prospects for a happy and healthy life. A life that enables their full participation as citizens. High density traffic, air pollution and limited urban green spaces mean that many children find it hard to avoid such dangers. Children are most vulnerable to these environments as they have a longer lifetime of exposure and are more immature in their ability to mitigate the effects.3-5 The UNICEF report card is quite different from its predecessors in two main ways: it focuses on environments that are either positive or negative for childhoods, rather than on measuring and ranking outcomes; and it used high quality data that in many cases did not depend on the nations to provide it. This independently collected information is comparable across time and between geographic locations. The data are used to rank countries across expanding sets of environments: those close to the child such as air, noise and light pollution, water quality, heat and cold, toxicants and pesticides. The next level of environments are community spaces — the area of green spaces and play facilities, housing quality, public transport, walkability and traffic. The overarching global influences include emissions, waste and recycling, management of the natural environment, climate change and natural disasters, renewable energy and housing, transport, and food policies. Australia performs very badly in the broader category of the world at large, both historically and currently. Australia had very low rankings on areas that should guide our climate and environmental policies.1, 3 We produced 21.7 kg of electronic waste per person per year, ranking 38 out of 43. Our consumption-based carbon dioxide (CO2) emissions since the Kyoto protocol was adopted in 1997 were 14.8 tonnes per person per year, ranking 39 out of 43 (with the United States and Canada). Australia, the US and Canada emitted more metric tonnes of CO2 per capita than any other Organisation for Economic Co-operation and Development (OECD) country. Yet you still hear arguments that we are so small that our emissions contribute very little. If the rest of the world behaved like Australia, we would need five planets Earth to ensure survival for us and our children. Thus, as global citizens we perform very badly indeed. Despite recent changes in government rhetoric, there are still large sections of politics and industry wedded to coal-fired electricity generation. In addition, gas developments are still being approved, even on sacred Indigenous lands. In the overall league table, 43 OECD countries are ranked in these three environmental domains. Australia ranks at 30 with Canada (28), Latvia (29) Israel (34) and the US (37). Spain is ranked 1 and clearly performs better than most in all three environmental domains. But no country does well overall and there is obviously substantial room for improvement in all countries. The report highlights how these analyses link to both the UN Convention on the Rights of the Child and the Sustainable Development Goals. So why do we rank so low? Australia ranks well on current air pollution from particulate matter 2.5 (exposure in parts per million), not so well in water-related morbidity of children aged less than 15 years (maybe influenced by our poor regional and remote water quality),6-9 too many of our children have high levels of lead compared with children from other OECD countries and more of our children are exposed to pesticide and other chemical pollution. Although Australia rated well on air pollution at the population level, the report did not measure the main pollutant from vehicle emissions (nitrogen dioxide), which we know is poor in certain parts of the country (eg, Melbourne's Inner West).10 Similarly, although water sustainability rated well, access to fresh drinkable water is poor in many rural and remote communities, especially those housing Indigenous children.6-9 Even though there were no analyses by subpopulation, the data clearly showed that people who are poorer and marginalised (eg, Aboriginal and Torres Strait Islander people) are more likely to have less capacity to cope with the stresses and environmental conditions outlined in this report. Much data collected in Australia relevant to child wellbeing are not categorised by subpopulations,8, 11 making meaningful examinations of disadvantage impossible. There are a number of climate and sustainability issues that are highly relevant to our children. Australia is experiencing unprecedented and extreme floods, fires, major heatwaves, and drought. These events lead to major changes in land use, population displacement, and disruption to children's schooling. The impacts of such events on mental health are being recognised, but perhaps less evident is an increase in child anxiety.12 A global survey of 10 000 children and young people conducted in mid-2021 reported that 82% of Australian children were at least moderately worried about climate change, with 32% reporting their anxiety negatively affected their functioning.12 Similar data were reported in the UNICEF report, with just over 40% of Australian young people stating they would be hesitant about having children due to climate change and a staggering 60% reporting beliefs that their government was betraying them and their future due to inadequate climate policies.3 One of the sustainability issues highlighted by the WHO–UNICEF–Lancet Commission report affecting children's future was predatory marketing.1 Children are specifically targeted by marketing of unhealthy and unsafe products, especially related to cigarettes and electronic cigarettes, junk food (high in calories, fat, sugar and salt), gambling, and sexualisation of children. Much attention has been paid to junk food and to sexualisation of children, and although these remain problems for Australian children, more attention needs to be paid to electronic cigarettes and gambling. Despite officially not available to Australian children, electronic cigarettes are becoming a growing problem, increasing exposure to toxic chemicals and nicotine, even in those claiming not to include nicotine.13, 14 A major problem facing Australia's children is the enormous penetration of the gambling industry into their lives. It is not possible to watch sport without being bombarded by gambling advertising. Children readily recognise logos of gambling companies and are gaining the impression that gambling is harmless — after all if you lose you get your money back.15, 16 What is perhaps more disturbing are the political donations from the gambling industry that are currently attracting media attention, which is reminiscent of the past behaviour of the tobacco industry.17, 18 We encourage UNICEF to include measures of predatory marketing practices in their next report card. There are glimmers of hope on the horizon, with a public backlash against gambling advertising during televised sport. Very recently, a public push has emerged for the government to implement a comprehensive ban on sports gambling advertising following the release of the report from the Parliamentary Inquiry on Online Gambling and its Impacts on Those Experiencing Harm.19 Support is increasing among players of some sporting teams for their clubs to reduce reliance on gambling revenue. So, how can we improve the future of Australia's children and young people? Several groups, including an offshoot from the WHO–UNICEF–Lancet Commission known as CAP-2030 (Children in All Policies 2030; https://cap-2030.org/), have suggested viewing all government policy through a child's lens. This would see the responsible Minister explain to Cabinet how the new policy being promoted would affect children if adopted. This would advance several important goals; for example, the impacts on children would be actively considered, the natural government silos would be opened, and governments would be forced to think beyond the next election when framing policy. In addition, publicising the UNICEF Innocenti report widely and making Australia's ranking an instrument by which politicians can be held accountable would improve our children's future. Turning things around in the environment and sustainability domain is crucial to all living beings, as the goal of keeping global warming within 2°C is slipping further and further out of sight. Key indicators that can help us track our progress in this domain and ensure we can make a difference in this area for children, young people and future generations by 2030 include consumption-based CO2 emissions, metric tonnes per capita; and the ratio of a country's ecological footprint to its biocapacity. In addition, we call for indicators of predatory marketing practices, such as electronic cigarettes, gambling and junk food. Our children are our future, but their future is under threat. A concerted effort is required to change this situation and putting children at the centre of all policy decisions would be a good start. This article is part of the MJA supplement on the Future Healthy Countdown 2030, which was funded by the Victorian Health Promotion Foundation (VicHealth) — a pioneer in health promotion that was established by the Parliament of Victoria as part of the Tobacco Act 1987, and an organisation that is primarily focused on promoting good health and preventing chronic disease for all. VicHealth has played a convening role in scoping and commissioning the articles contained in the supplement. Open access publishing facilitated by The University of Queensland, as part of the Wiley - The University of Queensland agreement via the Council of Australian University Librarians. No relevant disclosures. Commissioned; externally peer reviewed.

Until the recent death in Dubbo of an Aboriginal man, there have been no deaths from Covid 19 in Australia. The extraordinary success of Aboriginal and Torres Strait Islander populations in controlling the effects of this pandemic has been a global role model. Until early 2021, in spite of their high risk status, dispersed population and fear of health services due to racism, Indigenous outcomes were better than those for non‐Indigenous. Aboriginal health leaders at every level brought in worlds best practices and applied them in all urban, rural and remote locations. Instead of the many hundreds of cases, hospitalisation and deaths expected, there were only 150 cases nationwide with15% hospitalised but no one in ICU and no deaths. This result is a complete reversal of the gap and was due to the outstanding Indigenous leadership, that governments at all levels listened to Aboriginal wisdom and that control was handed to those who knew what to do. This result is not only evidence for why a Voice enshrined in the Constitution would work, it heralds a new way of working with Aboriginal people in Australia. This viewpoint makes the case for a different model to engage and empower First Nations to really close the gap ‐ themselves.

We can yet make amends, manage our impact, change the direction of our development and once again become a species in harmony with nature. All we require is the will. – David Attenborough1 David Attenborough is 94 and has probably seen more of the natural world than anyone alive. If you have not read his most recent book,1 we would like to politely suggest that you do so. His initial chapters which describe clearly, without blame, what we human beings have inadvertently done and continue to do to the planet are confronting. But his vision for the future is optimistic, concluding that we have it in our power to reverse our destruction of habitats like rainforests with its resultant loss of biodiversity, and reverse our pollution and over-fishing of oceans through the intelligent use of natural resources. David Attenborough wants us to stop concentrating on short-term, myopic economic gains and to ‘rewild the world’. We can only promote his message and hope world leaders listen. Attenborough's book gives clues as to how every one of us can do our bit to make a difference. Loren Eiseley (1907–1977), an American philosopher, anthropologist and natural science writer wrote a story called the Star Thrower2 (Fig. 1), which inspired many including Mahatma Gandhi. The story has been re-told in many forms, including as a children's book with a child as the hero. One such version tells of an old man (in some versions, he is an author with writer's block) walking along a beach. He sees a little girl happily throwing starfish into the ocean. He asks what she is doing. ‘Throwing starfish back into the ocean. The tide is out and if I don't throw them in, they will die’. He replies, ‘Don't be silly, there are thousands of starfish, you can't make a difference’. She looks at the one in her hand and says, ‘It will make a difference to this one’. Chastened, the man joins her (and the author overcomes his block and writes about it). So what can we do, each one of us? We will begin with one simple thing you as an individual could do. Currently, we cut down over 15 billion trees a year.1 We have reduced the world's rainforests by half, although rainforests are the most biodiverse places in the world, containing more than half of its land-living species (David Attenborough argues convincingly for the vital importance of biodiversity).1 The main driver by far of continuing deforestation is beef production.1 Beef makes up 25% of our meat consumption but we dedicate 60% of our farmland to raising it.1 It takes almost 9 units of edible crops to raise 1 unit of beef, 5 to raise 1 unit of pork and over 2 to raise 1 unit of chicken.3 We give antibiotics routinely to animals, not to cure diseases but to increase yield, risking antibiotic resistance out of greed.4 Those are powerful reasons to give up eating meat. If you cannot bear to give up meat altogether, Attenborough says if we all eat more plant-based foods and less meat (particularly beef) and dairy, it will make a huge difference.1 Many public health proponents will tell you it is also good for your own health. Another major source of energy expenditure we could easily reduce is transport. There is an irony in taking the moral high ground on North Americans' insistence on their right to bear arms to the detriment of others, when so many of us drive large vehicles which guzzle fossil fuel and are more likely to cause fatal accidents. How did we let ourselves be seduced by these monstrosities? Some years ago, DI traded his car for a hybrid. When he boasted about it, a friend retorted: ‘Now you'll have smug coming out your rear end’. Touché. We make excuses for driving to work, usually alone, when we know there are ways we could save energy by better use of public transport, car sharing, cycling, walking or working from home. We are as guilty as anyone else for driving into work alone regularly, for convenience sake. Getting out of your car, even an electric one, and walking or cycling5 will not only reduce emissions, but it is also good for your health and well-being. As we write this, we are thinking how we can make our daily travel more energy-efficient, then telling ourselves we must actually do it, not just think about it. Our children have led the way in exposing our own inaction.6 We waste a huge amount of energy in our home and work lives. Simply switching off computers, lights and fans when we stop using them makes a big difference. Introducing automated systems in hospitals and elsewhere to save energy eventually saves money, although there is frequently considerable resistance to spending money now to save in future. Individual improvements are not all that paediatricians can achieve. Paediatricians arguably have far more power to influence the political agenda than they realise. People who work in child heath come with integrity and knowledge about the impacts of these changes on our children. Their only vested interest is to care for children, in contrast to others with significant conflicts of interest. Paediatricians need to advocate that it is vital for the current and future health of children to address climate change. Currently, the powerful fossil fuel industry lobby is having more impact than the experts and the evidence on the health and well-being of the world's children. The science on the causes and impact of climate change is clear and the ways in which countries and their citizens need to act are also clear. The most important is that we stop mining and burning fossil fuels. We need to retain our old forests and plant new ones. We need to consume less – energy in particular, but also reduce the variety of other activities that increase our carbon and biodegradation footprint. The very young and the very old are the most vulnerable to the effects of climate change. The innocent and non-consenting victims of climate change (our children) will have a lifetime of exposure to heatwaves, pollution from bushfires and coal burning and the other effects, including mental health problems. According to recent statistics, children already suffer around 90% of the global disease burden from climate change, mostly occurring in developing countries which are the least responsible for climate change.7 Globally, for children under 5 years of age, climate change is predicted to worsen all of the top five causes of death (malnutrition, neonatal conditions, acute respiratory illness, diarrhoea and malaria).8 Figure 2 shows ways in which climate change can influence a range of child health outcomes. Whilst obviously more research is needed to support these claims, we have enough information to act now. Because of the particular vulnerability of children and the way that climate change will amplify existing inequities in disease burden, it is not possible to adequately prevent disease and improve child health without acknowledging and attempting to reverse the factors that create the social and economic gradients in child health outcomes. Predatory capitalism–consumerism has created an environment where we and our children have become dehumanised objects in service of the corporate bottom line and shareholder profits. This is the big driver of environmental degradation and climate change. In Australia today, those making most decisions about the health and well-being of our children are the fossil fuel industry, the alcohol industry, the tobacco industry and the food corporations. Where are the paediatricians in all this? We need to step up and advocate for children. We liken this opportunity to that of the Apartheid system in South Africa. If you were a doctor in that system, the only way to improve the health and well-being outcomes of your population was to eliminate Apartheid. We challenge you all, and the colleges and organisations to which you belong, to step up and take the lead of the children's marches for climate action and attempt to influence our governments. We have no time to lose and we would be joining the increasing numbers of doctors world-wide who are campaigning for climate action. It is not too late to listen to Australia's First Nations people, the world's longest surviving human civilisation, who lived in harmony with the land for over 60 000 years before the Industrial Revolution saw us start to destroy the land.9 Regenerative agriculture also offers the hope of improving soil health to reverse some of the effects of climate change.10 David Attenborough concludes that in a thriving, sustainable future, we would adopt a largely plant-based diet, use clean energy for all our needs and generate minimal waste.1 We can all do our bit to help achieve that future. His book should be mandatory reading for all health-care professionals, but also for all politicians world-wide. The Lancet has led the way on how doctors should respond to climate change with the Lancet Countdown; it has now concentrated on putting the health of children at the forefront with its Children in All Policies 2030 initiative.11 It is time for paediatricians to act.

Objective: The aim was to determine literacy and numeracy outcomes, among children with and without ADHD by gestational age and gender. Method: De-identified linked population data from the Western Australian Monitoring of Drugs of Dependence System and Western Australian Literacy and Numeracy Assessment databases, and the Midwives Notification System used information on 6,819 children with ADHD compared with 14,451 non-ADHD children. Results: A total of 23% of boys and 28% of girls with ADHD had numeracy scores below the benchmark in School Year 3, compared with 11% of children without ADHD. These differences were also evident for reading, writing, and spelling through primary school. Children with ADHD and reduced gestational age were at a greater risk of not meeting numeracy and reading benchmarks, compared with children born at term. Conclusion: Children with ADHD are disadvantaged from an early age in key areas of learning, and this risk increased with reduction in gestational age at birth.

This five-year study investigated the cultural birthing practices, needs and requirements of Aboriginal women giving birth in urban settings, and their experiences of maternity care and views of birthing on Country. It also investigated how midwives perceive and support cultural security. The paper highlights the selection of research methods that complemented the project's Indigenous methodological framework. Cultural lenses and diverse expertise translated the outcomes to recommendations about a culturally meaningful health system and professional practice and education aimed at supporting Aboriginal women's birthing expectations in the future. Our tailored research practices privileged culturally secure approaches to push back against Western knowledge paradigms that have dominated qualitative research undertaken with Aboriginal people. This paper describes the research methods chosen to manage complex data collection and analysis, and how we blended Indigenous-specific methods with compatible standard methods to support Indigenist and decolonising research practices. We include Aboriginal researcher reflections to highlight the importance of culturally determined research processes that result in high-quality, culturally meaningful research.

Tackling a health crisis such as COVID-19, with society in lockdown can’t help but place families under strain. It’s been reported family violence notifications to police nearly tripled in some areas of China’s Hubei province (where SARS-CoV-2, the virus that causes COVID-19 originated) during the lockdown in February. Some family violence organisations in Australia are already reporting a rise in demand for services. The federal government recently announced A$1.1 billion for mental health services, domestic violence support and Medicare assistance for people at home, and emergency food relief. This support is welcome but more practical and creative measures are also required to protect vulnerable families.

BACKGROUND:Perinatal mortality rates are typically higher in Aboriginal than non-Aboriginal populations of Australia. OBJECTIVES:This study aimed to examine the pattern of stillbirth and neonatal mortality rate disparities over time in Western Australia, including an evaluation of these disparities across gestational age groupings. METHODS:All singleton births (≥20 weeks gestation) in Western Australia between 1980 and 2015 were included. Linked data were obtained from core population health datasets of Western Australia. Stillbirth and neonatal mortality rates and percentage changes in the rates over time were calculated by Aboriginal status and gestational age categories. RESULTS:From 1980 to 2015, data were available for 930 926 births (925 715 livebirths, 5211 stillbirths and 2476 neonatal deaths). Over the study period, there was a substantial reduction in both the Aboriginal (19.6%) and non-Aboriginal (32.3%) stillbirth rates. These reductions were evident in most gestational age categories among non-Aboriginal births and in Aboriginal term births. Concomitantly, neonatal mortality rates decreased in all gestational age windows for both populations, ranging from 32.1% to 77.5%. The overall stillbirth and neonatal mortality rate differences between Aboriginal and non-Aboriginal birth decreased by 0.6 per 1000 births and 3.9 per 1000 livebirths, respectively, although the rate ratios (RR 2.51, 95% CI 2.14, 2.94) and (RR 2.94, 95% CI 2.24, 3.85), respectively reflect a persistent excess of Aboriginal perinatal mortality across the study period. CONCLUSIONS:Despite steady improvements in perinatal mortality rates in Western Australia over 3½ decades, the gap between Aboriginal and non-Aboriginal rates remains unchanged in relative terms. There is a continuing, pressing need to address modifiable risk factors for preventable early mortality in Aboriginal populations.

Aboriginal infants have poorer birth outcomes than non-Aboriginal infants. Harmful use of tobacco, alcohol, and other substances is higher among Aboriginal women, as is violence, due to factors such as intergenerational trauma and poverty. We estimated the proportion of small for gestational age (SGA) births, preterm births, and perinatal deaths that could be attributed to these risks. Birth, hospital, mental health, and death records for Aboriginal singleton infants born in Western Australia from 1998 to 2010 and their parents were linked. Using logistic regression with a generalized estimating equation approach, associations with birth outcomes and population attributable fractions were estimated after adjusting for demographic factors and maternal health during pregnancy. Of 28,119 births, 16% of infants were SGA, 13% were preterm, and 2% died perinatally. 51% of infants were exposed in utero to at least one of the risk factors and the fractions attributable to them were 37% (SGA), 16% (preterm) and 20% (perinatal death). A large proportion of adverse outcomes were attributable to the modifiable risk factors of substance use and assault. Significant improvements in Aboriginal perinatal health are likely to follow reductions in these risk factors. These results highlight the importance of identifying and implementing risk reduction measures which are effective in, and supported by, Aboriginal women, families, and communities.

Objective To describe the long-term neurodevelopmental and cognitive outcomes for children born preterm. Study design In this retrospective cohort study, information on children born in Western Australia between 1983 and 2010 was obtained through linkage to population databases on births, deaths, and disabilities. For the purpose of this study, disability was defined as a diagnosis of intellectual disability, autism, or cerebral palsy. The Kaplan-Meier method was used to estimate the probability of disability-free survival up to age 25 years by gestational age. The effect of covariates and predicted survival was examined using parametric survival models. Results Of the 720 901 recorded live births, 12 083 children were diagnosed with disability, and 5662 died without any disability diagnosis. The estimated probability of disability-free survival to 25 years was 4.1% for those born at gestational age 22 weeks, 19.7% for those born at 23 weeks, 42.4% for those born at 24 weeks, 53.0% for those born at 25 weeks, 78.3% for those born at 28 weeks, and 97.2% for those born full term (39-41 weeks). There was substantial disparity in the predicted probability of disability-free survival for children born at all gestational ages by birth profile, with 5-year estimates of 4.9% and 10.4% among Aboriginal and Caucasian populations, respectively, born at 24-27 weeks and considered at high risk (based on low Apgar score, male sex, low sociodemographic status, and remote region of residence) and 91.2% and 93.3%, respectively, for those at low risk (ie, high Apgar score, female sex, high sociodemographic status, residence in a major city). Conclusions Apgar score, birth weight, sex, socioeconomic status, and maternal ethnicity, in addition to gestational age, have pronounced impacts on disability-free survival.

ObjectivesThe removal of a child from their parents is traumatising, particularly in Aboriginal communities where a history of child removals has led to intergenerational trauma. This study will determine where disparities in child protection involvement exist among Aboriginal and non-Aboriginal children and characteristics associated with infant removals. Challenges faced by child protection and other agencies, and opportunities for overcoming these, are discussed.MethodsData from both the Australian Institute of Health and Welfare and linked Western Australian government data was used to examine disparities between Aboriginal and non-Aboriginal children in the child protection and out-of-home care system.ResultsNationally, Aboriginal children are ten times more likely to be placed in out-of-home care than non-Aboriginal children and this disparity starts in infancy. Infants were removed from parents with high levels of risk. Aboriginal infants were at increased risk of being removed from women with substance-use problems and had greater proportions removed from remote, disadvantaged communities than were non-Aboriginal infants.ConclusionsAboriginal infants have a high rate of removal. Although there are many complexities to be understood and challenges to overcome, there are also potential strategies. The disparity between Aboriginal and non-Aboriginal infant removals needs to be seen as a priority requiring urgent action to prevent further intergenerational trauma.

The Australian Government's contemptuous dismissal of the latest report of the Intergovernmental Panel on Climate Change (IPCC), including the panel's recommendation to dramatically reduce coal power by 2050, is unacceptable. As Australian health professionals and scientists, we are dismayed by the implications of our government's ongoing stance to disregard the consensus of the world's leading climate scientists, the precautionary principle, and any idea of duty of care regarding the future wellbeing of Australians and our immediate neighbours. Australia is the world's largest coal exporter and produces about 7% of the world's coal.1Smith R These are the world's biggest coal producers. World Economic Forum, Geneva2018https://www.weforum.org/agenda/2018/01/these-are-the-worlds-biggest-coal-producers/Date accessed: October 18, 2018Google Scholar Worldwide, fossil fuel burning produces around 72% of all greenhouse gas emissions resulting from human activities.2Watts N Amann M Ayeb-Karlsson S et al.The Lancet Countdown on health and climate change: from 25 years of inaction to a global transformation for public health.Lancet. 2018; 391: 581-630Summary Full Text Full Text PDF PubMed Scopus (436) Google Scholar To limit global warming to 2°C, a third of oil reserves, half of gas reserves, and more than 80% of current coal reserves as of 2010 should remain unused.3McGlade C Eakins P The geographical distribution of fossil fuels unused when limiting global warming to 2°C.Nature. 2015; 517: 187-190Crossref PubMed Scopus (811) Google Scholar Air pollution from coal burning is responsible for numerous health problems—according to the Global Burden of Disease Study 2016,4GBD 2016 Risk Factors CollaboratorsGlobal, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016.Lancet. 2017; 390: 1345-1422Summary Full Text Full Text PDF PubMed Scopus (1219) Google Scholar around 2·5 million deaths were caused by solid fuel burning worldwide. Ironically, no other member country of the Organisation for Economic Co-operation and Development is as vulnerable to climate disruption as Australia.5Paun A Acton L Chan W-S Fragile planet: scoring climate risks around the world. HSBC Global Research.https://www.sustainablefinance.hsbc.com/our-reports/fragile-planetDate: 2018Date accessed: October 18, 2018Google Scholar Climate disruption is already amplifying the frequency, intensity, and duration of extreme weather events such as heatwaves, bushfires, drought, and tropical storms, causing harm and damaging livelihoods. As with other established historical harms to human health (eg, tobacco and exorbitant hepatitis C drug prices), narrow vested interests must be countered to bring about fundamental change in the consumption of coal and other fossil fuels. The Australian Government must commit immediately to embrace strategies of energy generation that do not put more greenhouse gases into the atmosphere (panel)—with healthier communities reaping the benefits now and in the future. Without concerted action by all, the IPCC recommendation to achieve net zero carbon emissions by 2050 will certainly not be achieved.PanelCall to actionAs Australian health professionals in clinical medicine, public health, research, and education, we ask national and international communities to support these calls on our government to protect the health of current and future generations nationally and globally.•Commit to no new or expanded coal mines and no new coal-fired power stations, phase out existing coal-fired power stations, and rapidly remove all subsidies to fossil fuel industries; the Adani coal mine must not proceed•Increase the national renewable energy target to at least 50% by 2030•Develop multisector regional development transition plans for communities and regions affected by the progressive phase-out of fossil fuel industries•Review Australia's Nationally Determined Contributions to the Paris Agreement (a requirement of signing the agreement), and develop a plan to reduce carbon emissions by at least 50% by 2030, compared with 2005•Support Pacific Island nations to prepare for and adapt to the effects of climate change As Australian health professionals in clinical medicine, public health, research, and education, we ask national and international communities to support these calls on our government to protect the health of current and future generations nationally and globally. •Commit to no new or expanded coal mines and no new coal-fired power stations, phase out existing coal-fired power stations, and rapidly remove all subsidies to fossil fuel industries; the Adani coal mine must not proceed•Increase the national renewable energy target to at least 50% by 2030•Develop multisector regional development transition plans for communities and regions affected by the progressive phase-out of fossil fuel industries•Review Australia's Nationally Determined Contributions to the Paris Agreement (a requirement of signing the agreement), and develop a plan to reduce carbon emissions by at least 50% by 2030, compared with 2005•Support Pacific Island nations to prepare for and adapt to the effects of climate change Because of processes of colonisation and marginalisation, Aboriginal and Torres Strait Islander communities in Australia have been cut off from lands and seas and are in poorer overall health; climate change will only amplify these inequities. Australia's Pacific Island neighbours are also highly vulnerable6McIver L Kim R Woodward A et al.Health impacts of climate change in Pacific Island countries: a regional assessment of vulnerabilities and adaptation priorities.Environ Health Perspect. 2016; 124: 1707-1714Crossref PubMed Scopus (65) Google Scholar to climate-related risks to health, extreme weather events, rising sea levels, coastal erosion, habitability, food security, water supply, and economic growth. Our disregard of their plight through continued coal burning is shameful. This online publication has been corrected. The corrected version first appeared at thelancet.com on November 15, 2018 This online publication has been corrected. The corrected version first appeared at thelancet.com on November 15, 2018 SLo is Consulting Editor at The Lancet. NT is Editor in Chief of the Medical Journal of Australia. NW declares grants from the Wellcome Trust. All other authors declare no competing interests. Department of ErrorArabena K, Armstrong F, Berry H, et al. Australian health professionals' statement on climate change and health. Lancet 2018; 392: 2169—In this Correspondence, Nicholas Talley's name has been corrected to "Nicholas J Talley", and his affiliation has been corrected to "University of Newcastle, Newcastle, NSW, Australia". These corrections have been made to the online version as of Nov 15, 2018, and have been made to the printed version. Full-Text PDF

The association between a single interpregnancy interval (IPI) and birth outcomes has not yet been explored using matched methods. We modeled the odds of preterm birth, being small for gestational age, and having low birth weight in a second, live-born infant in a cohort of 192,041 sibling pairs born in Western Australia between 1980 and 2010. The association between IPI and birth outcomes was estimated from the interaction between birth order and IPI (with 18-23 months as the reference category), using conditional logistic regression. Matched analysis showed the odds of preterm birth were higher for siblings born following an IPI of <6 months (adjusted interaction odds ratio = 1.22, 95% confidence interval: 1.06, 1.38) compared with those born after an IPI of 18-23 months. There were no significant differences for IPIs of <6 months for other outcomes (small for gestational age or low birth weight). This is the first study to use matched analyses to investigate the association between a single IPI on birth outcomes. IPIs of <6 months were associated with increased odds of preterm birth in second-born infants, although the association is likely smaller than previously estimated by unmatched studies.