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Abstract

Background and Purpose

This qualitative study is part of a larger Indigenous community-led project in Southern Ontario, Canada, to support Indigenous fathers and Two-Spirit parents through the development of a culturally relevant parenting program. Conducted during Phase 2, this study pretested six well-established instruments to assess their clarity, comprehension, and cultural safety for use in evaluating the parenting program in Phase 3.

Methods and Procedures

Six participants, all of whom were First Nations or Métis, either expecting a baby or parenting a child under the age of three, completed five instruments, specifically the Parenting Sense of Competence Scale (PSOC), Edinburgh Postnatal Depression Scale (EPDS), Relationship Assessment Scale (RAS), General Self-Efficacy Scale (GSES), and either the Paternal Antenatal Attachment Scale (PAAS) or Paternal Postnatal Attachment Scale (PPAS). Semi-structured interviews were conducted to gather insights on the instruments’ instructions, terminology, response scales, and cultural relevance. Data were analyzed using conventional content analysis.

Results

Participants identified barriers to understanding and accurately completing the instruments, including challenging terminology, ambiguous response scales, and cultural safety concerns. Recommendations included simplifying language, clarifying scale anchors, adding culturally relevant questions, and establishing culturally safe support pathways for participants disclosing distress.

Conclusion

Euro-Western developed instruments require refinement to ensure accessibility, cultural relevance, and safety for Indigenous fathers and Two-Spirit parents. This includes adapting tools to reflect Indigenous literacy frameworks and holistic wellness perspectives. This study underscores the ethical imperative for researchers to ensure cultural appropriateness and safety when engaging Indigenous communities in research.

Keywords

Indigenous fathers two-spirit parents cultural safety parenting competence postpartum mental health psychometric validation

Background and Purpose

Colonial policies and practices have disrupted traditional parenting roles in Indigenous communities, limiting opportunities for men to access culturally relevant supports and fully engage in fatherhood (Ball, 2010; Cabrera et al., 2018; Canuto et al., 2019; Gerlach et al., 2017). Although father involvement, measured in some studies as direct caregiving (e.g., feeding, soothing, bathing), time spent with the infant, parenting self-efficacy, and material support, has been shown to lower infant mortality, foster secure attachment, and reduce cognitive delays and parental depression (Allport et al., 2018; Bamishigbin et al., 2020; Dikmen-Yildiz, 2025; Filippa et al., 2021), little is known about the experiences of Indigenous fathers. Existing parenting programs are often designed through Eurocentric, mother-focused lenses, resulting in the underrepresentation or exclusion of fathers (Ball, 2010; Gerlach et al., 2017; Reilly & Rees, 2018). In Indigenous contexts, fatherhood uniquely encompasses roles in cultural transmission, kinship care, and community stewardship, often enacted through “circles of care” where men mentor youth. These roles have been systematically eroded by colonial policies like residential schools and positioned Indigenous men as absent or inadequate providers (Ball, 2009, 2010; Canuto et al., 2019). This legacy has led to intergenerational trauma, socioeconomic marginalization, and exclusion from family supports, exacerbating mental health challenges and limiting men's participation in child-rearing (Hall et al., 2020; Reilly & Rees, 2018). Unlike Euro-Western models emphasizing direct caregiving, Indigenous fatherhood prioritizes holistic wellbeing and relational responsibilities, yet programs remain mother-centric, overlooking these distinctions (Gerlach et al., 2017). Two-Spirit parents also play vital roles in Indigenous communities, enriching family dynamics and cultural continuity. The term Two-Spirit is a culturally inclusive term that honours the varied gender identities, roles, and expressions among Indigenous Peoples, linking them to the traditional practices of gender diversity unique to their Nations (Carrier et al., 2020; Dykhuizen et al., 2022; Hunt, 2015; Innes & Anderson, 2015). In this article, we use Two-Spirit parent to acknowledge participants who identify as Two-Spirit and hold parenting roles, recognizing that some may not identify with the gendered term “father”. Two-Spirit parents often face distinct obstacles, such as homophobia and transphobia that hinder their access to culturally safe resources and services (Carrier et al., 2020; Dykhuizen et al., 2022).

To address the gap in understanding Indigenous fathers’ experiences and the lack of a parenting program focused on fathers, a Steering Committee of Indigenous community members designed a parenting program tailored to Indigenous fathers and Two-Spirit parents as part of large three-phased project titled Fathers of the Next Generation. The study presented in this article is Phase 2 of the larger project to develop and evaluate the Fathers of the Next Generation parenting program. The aim of this study was to pretest six instruments —the Parenting Sense of Competence Scale (PSOC), Edinburgh Postnatal Depression Scale (EPDS), Relationship Assessment Scale (RAS), General Self-Efficacy Scale (GSES), Paternal Antenatal Attachment Scale (PAAS), and Paternal Postnatal Attachment Scale (PPAS)—for clarity, comprehension, and cultural safety with Indigenous fathers and Two-Spirit parents living in Southern Ontario. The study results will inform any instrument adaptations needed. In Phase 3 of the project, these adapted instruments will undergo formal psychometric testing to be used to evaluate the effectiveness of the parenting program.

The Steering Committee, consisting of First Nations and Métis fathers, mothers, Two-Spirit parents, a First Nation Knowledge Holder, program delivery specialists, Indigenous-led community partners (including the Hamilton Regional Indian Centre, Indigenous Diabetes Health Circle, Six Nations of the Grand Rivier Birthing Centre, and Six Nations of the Grand River Social Services) and First Nation and non-Indigenous scholars from Southern Ontario, Canada, designed the three-phased study to develop and evaluate the Fathers of the Next Generation parenting program. In Phase 1, the Steering Committee sought to understand the experiences and needs of Indigenous men and Two-Spirit people as they transition to their role as parents. Embarking on a Journey to Fatherhood was found to involve five phases: visioning fatherhood, planning for fatherhood, birth of a baby, pursuing fatherhood, and navigating fatherhood (VanEvery et al., 2025). In Phase 2, the Steering Committee, along with members of the wider Indigenous community led the development of a six-topic, in-person parenting program, aimed to equip Indigenous fathers and Two-Spirit parents with culturally relevant information about pregnancy, birth, and the newborn period. In Phase 3, the Steering Committee will deliver the parenting program exclusively to Indigenous fathers and Two-Spirit parents and evaluate its effectiveness using the six instruments refined in this study (Phase 2). These instruments will measure changes in perceived parenting competence and wellness.

Several reliable and valid instruments are available to measure the intended outcomes of the parenting program (e.g., Parenting Sense of Competence Scale, Edinburgh Postnatal Depression Scale). Within the field of measurement, however, instruments must not only have strong psychometric properties but also be pretested with the target population to be valid. Tools such as the Parenting Sense of Competence Scale (Gibaud-Wallston & Wandersman, 1978), exhibit robust psychometric properties across diverse contexts and languages (Delhalle et al., 2024; Gilmore & Cuskelly, 2023; Nunes et al., 2023), but lack validation amongst Indigenous Peoples. This lack of testing is critical, as psychometrically sound tools, often developed within Euro-Western cultural frameworks, may not adequately capture the unique experiences of Indigenous Peoples due to cultural misalignment (Westerman & Dear, 2023). Other tools, such as the Edinburgh Postnatal Depression Scale which examines mental health (Cox et al., 1987), have undergone cultural validation with a sample of First Nations and Métis women in Canada (Chan et al., 2021), but the scale has not been validity tested with Indigenous men or Two-Spirit people to determine if they are appropriate or safe for use. Furthermore, as Indigenous Peoples represent hundreds of different cultural groups with varying values and beliefs, it is important to distinguish which specific Indigenous cultures participants identify with. Without cultural validation, assessments may inaccurately reflect Indigenous fathers’ and Two-Spirit parents’ experiences.

Cultural safety, a core principle in this research, is when the individual defines what is safe, extending beyond cultural sensitivity to empower individuals in assessing their perceived risk or security (Koptie, 2009; Papps & Ramsden, 1996; Ramsden, 2002). The results of this study will support decision making about whether these tools are appropriate and safe for use with the Indigenous fathers and Two-Spirit parents who will be participating in the pilot of the Fathers of the Next Generation parenting program, in Hamilton, Ontario, or if adjustments to the tools must first be made prior to their use with a larger group of participants. Ethical approval for this study was obtained from the University of Toronto and the Six Nations of the Grand River Research Ethics Committee.

Methods and Procedures

Guiding Frameworks

This study used a community-engagement approach led by the Father of the Next Generation project's Steering Committee. The Steering Committee oversaw the design and implementation of the study. The Steering Committee's approach to community-engagement is guided by the Tekani teyothata’tye kaswenta, or Two Row Wampum, as described by Hill and Coleman (2019). The Two Row Wampum, an agreement between the local [First Nations] community (Haudenosaunee, otherwise known as Iroquois) and Dutch settlers, symbolizes a lasting commitment to friendship, respect, and peace. It provides a framework for ethical, culturally safe, and decolonized research partnerships based on respect, equity, ceremony, diversity, and shared knowledge (Hill & Coleman, 2019).

Study Design

This qualitative study, conducted during Phase 2 of a larger community-led project, used 1:1 semi-structured interviews with Indigenous fathers and Two-Spirit participants to assess the clarity, comprehension, and cultural safety of six validated psychometric instruments.

Instruments – Selection and Description

The Steering Committee collaboratively identified six instruments to evaluate Indigenous parenting program effectiveness on perceived competency and indicators of wellness (e.g., mental health, the Indigenous father's/Two-Spirit parent's relationship with the infant's mother, and self-efficacy) and infant attachment. These included the Parenting Sense of Competence Scale (PSOC) (Gibaud-Wallston & Wandersman, 1978); Edinburgh Postnatal Depression Scale (EPDS) (Cox et al., 1987); Relationship Assessment Scale (RAS) (Hendrick, 1988); General Self-Efficacy Scale (GSES) (Luszczynska et al., 2005); Paternal Antenatal Attachment Scale (PAAS) (Condon, 1993); and Paternal Postnatal Attachment Scale (PPAS) (Condon et al., 2008). Extensive research supports the strong psychometric properties of these instruments (Condon, 1993; Condon et al., 2008; Condon et al., 2013; Gibaud-Wallston & Wandersman, 1978; Hendrick et al., 1998; Johnston & Mash, 1989; Luszczynska et al., 2005; Matthey et al., 2001; Ohan et al., 2000; Scholz et al., 2002; Vaughn & Baier, 2010). The PSOC (Gibaud-Wallston & Wandersman, 1978), a 17-item self-report tool, assesses parental self-efficacy through two subscales: (1) parental satisfaction (encompassing parenting-related anxiety, motivation, and frustration) and (2) efficacy (covering competence, capability, and problem-solving in parenting). It has shown good internal consistency and concurrent validity with parents of infants and older children (Gibaud-Wallston & Wandersman, 1978; Johnston & Mash, 1989; Ohan et al., 2000). The EPDS (Cox et al., 1987) is a 10-item instrument for identifying depression and anxiety (Brouwers et al., 2001) during pregnancy and birth. Originally developed for mothers, it has been applied to fathers during prenatal and postnatal phases (Edmondson et al., 2010; Matthey et al., 2001; Paulson & Bazemore, 2010). With fathers, the EPDS has demonstrated strong internal reliability (alpha = 0.81) and is effective in detecting depression in men (Matthey et al., 2001). The tool has undergone cultural validation with First Nations and Métis women in Canada (Chan et al., 2021; Clarke, 2008). Clarke (2008) found an internal consistency alpha = 0.87 and demonstrated construct validity as the EPDS correlated significantly with the Beck Depression Inventory-II, r (94) = .71, p < .01. Additionally, a cutoff score of 11.5 yielded optimal sensitivity (94%) and specificity (86%) in identifying postpartum depression among First Nations and Métis women. The RAS (Hendrick, 1988) is a 7-item scale that evaluates global relationship satisfaction for couples in various intimate relationships, such as marriage and cohabitation. This valid and reliable measure (Hendrick et al., 1998) has demonstrated high internal consistency (alpha = 0.92) and strong convergent validity (Vaughn & Baier, 1999) with the Dyadic Adjustment Scale (Spanier, 1976), a tool assessing relationship quality. The GSES (Schwarzer & Jerusalem, 1995) is a 10-item self-report scale that measures perceived self-efficacy in adapting to daily life and stressful life events. Tested across 25 countries, it has demonstrated strong internal reliability (alpha = 0.76–0.90), negative correlations with depression, stress, and anxiety, and has been validated in multiple languages (Luszczynska et al., 2005; Scholz et al., 2002). The PAAS (Condon, 1993), a 16-item instrument, and its postnatal counterpart, the PPAS (Condon et al., 2008), which includes 19 items, measures the father-infant bond before and after birth, respectively. The PAAS and PPAS are among only four tools highlighted in a systematic review of bonding/attachment measures targeting fathers (Wittkowski et al., 2020). The PAAS has shown internal consistency with alpha > 0.8 and satisfactory construct validity (Condon, 1993). The PPAS exhibits good internal consistency (alpha = 0.7–0.8) (Condon et al., 2008), test-retest reliability (Condon et al., 2013), and construct validity (Condon et al., 2008, 2013), with negative correlations to EPDS scores or fussy infant temperament (Condon et al., 2008).

Sampling and Recruitment

Purposive and snowball sampling was used to recruit six (n = 6) Indigenous men and Two-Spirit individuals who were either expecting a baby or had a child under the age of three years. Given the small number of eligible participants in the community, snowball sampling was an important way to reach eligible parents with the study information. Recruitment was also supported by our community partners via word-of-mouth through their networks. Interested individuals contacted the research coordinator directly who shared with them a digital copy of the study letter and consent form and scheduled a time to meet online via Zoom. The research team aimed to recruit 10 participants, as literature indicates that samples of 5 to 15 participants are adequate for identifying most issues with question clarity, terminology, response options, and comprehension of instruments (Patel-Syed et al., 2024; Willis, 1999; Willis, 2005).

Data Collection

Individual 1:1 interviews were conducted via Zoom with each of the six participants, who first completed the assigned instruments and then participated in a semi-structured interview. Prior to completing the instruments, the interviewer explained the study's purpose, reviewed consent details, and answered questions. If participants wished to continue with the study, they provided verbal consent to the interviewer or were provided with a link to the online consent form on Research Electronic Data Capture (REDCap) where they provided written consent. Data were collected and managed using REDCap hosted at the University of Toronto (Harris et al., 2009, 2019). REDCap is a secure, web-based software platform designed to support data capture for research studies.

Participants completed assigned instruments based on whether they were expecting a child for the first time or were already a parent. One (n = 1) participant was expecting their first baby, thus completed the PSOC, EPDS, RAS, GSES, and PAAS (antenatal version of the attachment instrument). Five (n = 5) participants already had children, therefore completed four of the same instruments–the PSOC, EPDS, RAS, GSES, and the postnatal version of the attachment scale, the PPAS. Participants were asked to make note of any issues with instructions or questions while completing the instruments.

Next, immediately following instrument completion, a semi-structured interview was conducted by one of the Steering Committee members. The interview consisted of eight questions focused on the participant's assessment of the instrument (survey) instructions, the statements on the instruments, terminology used in the tool, and the instrument scale descriptors. These questions targeted the clarity, comprehension, and cultural appropriateness of the instruments (e.g., “Were there any questions you found confusing or difficult to answer?”, “Were there any questions that you found upsetting?”). Interviews lasted 15 to 40 min, were video- and/or audio-recorded, transcribed verbatim, and deidentified for analysis. Participants could choose to complete as many of the instruments as they preferred before discussing their responses, or they could complete all five instruments and then proceed to the interview.

Data Analysis

Conventional content analysis (Hsieh & Shannon, 2005) was used to assess participant feedback on the instruments. The research coordinator and research assistant (EMF, NG) independently reviewed the interview transcripts and summarized participants’ responses, organizing notes, comments, and recommendations in a Microsoft Excel document, where the feedback could be tracked alongside any future changes that were made to the tools following the study. They met to compare analytical notes, discuss interpretations, and reach consensus. Results were presented to the project Steering Committee for input and approval, and as a method of member checking with individuals who were parents, from similar cultures, and shared similar lived experience as the study participants.

Authors’ Positionality

EMF, a registered nurse and trained researcher of Jamaican and Filipino ancestry, is a mother of three and served as the research project coordinator for this study. MLB, a non-Indigenous nurse researcher and parent of two, specializes in neonatal care and healthy parenting, and has collaborated with the Hamilton Regional Indian Centre on research initiatives for the past four years. NG is a registered nurse specializing in labour and delivery nursing and public health, a mother of five with Jamaican and Guyanese ancestry, and supported the project as a research assistant. JD is a Two-Spirit, Métis nurse researcher who works with and for the Two-Spirit community. SDG, Onyota’á:ka (Oneida) Turtle Clan, is an Indigenous Midwife, International Board Certified Lactation Consultant, and educator. ALW, the principal investigator, is of Irish and Scottish descent and lives with her family on the traditional territories of the Mississauga and Haudenosaunee Nations. Her research has focused on community-driven priorities in partnership with Indigenous-led organizations for over 12 years.

Results

A total of six participants participated in the study. Of the six participants, five (83.3%) identified their gender as man and one (16.7%) as trans man. One of the participants who identified as a man also described themselves as Two-Spirit. Most participants (83.3%; n = 5) had at least one child and one participant (16.7%; n = 1) was expecting a child at the time of the study. Almost all participants (83.3%; n = 5) identified as First Nations, representing either Anishinaabe or Nations from Six Nations of the Grand River (Haudenosaunee Nations), while one participant identified as Métis. All participants were aged 30 to 39 years and had varying education levels: one third (33.3%; n = 2) had college or trade school diplomas/certificates; one (16.7%) had some university experience, and half (50.0%; n = 3) had university degrees. Five of the participants were married or in a common-law relationship, while the remaining participant was separated. All five participants who had a child were co-parenting with their child's other parent. The perspectives of Inuit were not represented in this study, as recruitment was conducted through partner organizations located in areas primarily serving First Nations and Métis communities.

The results from the participant interviews encompassed four main areas: comprehension of instrument instructions, terminology, and questions; item response options; cultural safety and recommended additions to the instruments. Each of these areas is discussed in the sections that follow, with examples of adaptations summarized in Table 1.

Table 1.

Examples of Adaptations to Pre-Existing Instruments Based on Feedback from Indigenous Fathers and Two-Spirit Parents.

Instrument	Issues Identified	Adaptation
Parenting Sense of Competence Scale (PSOC)	(a) Illogical order of response options: disagree, somewhat disagree, disagree, agree, somewhat agree, strongly agree.	(a) Use of the revised tool, PSOC-R (Gilmore & Cuskelly, 2023), which reorders response options to a more intuitive sequence: strongly disagree, disagree, mildly disagree, mildly agree, agree, strongly agree.
Parenting Sense of Competence Scale (PSOC)	(b) Uncertainty whether selecting strongly agree for the item “I sometimes feel like I’m not getting anything done” reflects actual productivity or just the feeling of not getting anything done.	(b) Use of the PSOC-R scale revised by Gilmore and Cuskelly (2023) to remove problematic items and add new ones (e.g., “I feel I am achieving my parenting goals”).
Edinburgh Postnatal Depression Scale (EPDS)	(a) Concerns with the self-harm item “The thought of harming myself has occurred to me”, such as the fear of mandatory reporting and inadequate follow-up with participants expressing distress.	(a) Added opening and closing messages to the beginning and end of the instrument, respectively, to support participant wellness, outline next steps for self-harm disclosures, and provide Indigenous-specific support options. For example: “Your wellbeing matters. If you’re feeling unsafe or struggling, we’ll check in and offer help, including emergency support if needed. We can connect you with Indigenous-specific resources. We’re here to ensure you feel safe and supported.”
Edinburgh Postnatal Depression Scale (EPDS)	(b) 7-day timeframe for items may not align with how participants experience or recall events.	(b) New item added to assess emotional wellness over a longer timeframe: “How would you rate your emotional wellness over the past 2 months?”
Relationship Assessment Scale (RAS)	(a) Confusion about whether 1 = low, 5 = high scale provided clear anchors. Participants found it difficult to interpret how the same response options applied across questions.	(a) Added item-specific descriptors to clarify response anchors while retaining the original scale range (“low” to “high”). For example, for item, “How well does your partner meet your needs?”, anchors were specified as 1 = not at all and 5 = very well. For item “How often do you wish you hadn’t gotten into this relationship?”, anchors were specified as 1 = never and 5 = very often.
General Self-Efficacy Scale (GSES)	(a) Unclear or awkward wording affected understanding. Such as, “efficiently” in the item, “I am confident that I could deal efficiently with unexpected events.”	(a) Added clarifying terms in parentheses to support understanding: For example, “I am confident that I could deal efficiently (quickly) with unexpected events.”
Paternal Antenatal/Postnatal Attachment Scale (PAAS/PPAS)	(a) Unnecessarily complex or awkward wording affecting comprehension (e.g., “developing baby”).	(a) Simplified language. For example, used “growing baby” instead of “developing baby”.

Note. Adaptations were made by consensus between the research team and Steering Committee.

Comprehension of Instrument Instructions, Terminology, and Questions

Most instrument instructions were reported by participants to be generally clear and not difficult to follow. However, one participant highlighted that the term, “developing baby” used in the instructions of the PAAS/PPAS, could be confusing for some parents. The participant suggested simplifying the language by using the term “growing baby” instead.

Participants noted unclear terminology and lack of context hindered comprehension of the questions. One participant believed the terminology on some instruments exceeded a 5th-grade reading level; this could impact comprehension of instrument questions for some participants. For example, on the GSES instrument, the participant identified the words “preoccupied”, “means,” and “resourcefulness” as potentially problematic. The participant stressed the importance of using simpler terminology: “It could be a simpler word, or “preoccupied”, could just be “busy”. Just simplifying some of the language…” This comment aligns with plain-language recommendations for research and health communication materials (Bauer et al., 2023; Stallwood et al., 2023; Tumiel-Berhalter & Ortiz, 2024). The recommendation to simplify the language also extended beyond terminology to instrument questions as a whole. One participant, for example, felt the item “I have looked forward with enjoyment to things” on the EPDS was problematic, and suggested the use of simpler phrasing throughout the tools: “I think it's just removing any of the extra wordiness, you know.” The emphasis on reducing wordiness echoes plain-language and culturally adapted approaches to designing depression screening tools for use with Indigenous populations (Brockie et al., 2022; Chan et al., 2021; Le Grande et al., 2017; Maar et al., 2011).

Some participants also wanted questions to be more specific. For example, a participant found the item “I can remain calm when facing difficulties because I can rely on my coping abilities” on the GSES to be too broad. They felt that their coping strategies differed between parenting and home- and work-life, suggesting the question be more specific to differentiate the areas of one's life in which coping strategies are used:

So it's like situationally, like I know that…you're likely asking for coping abilities as a parent right… it's just that I have coping abilities that I have for home life and I have coping abilities I have for work life, right?….It's just that I think that the question just needs to, just really say it's about coping and home life strategies.

This participant's call for more context-specific items aligns with evidence that the GSES assesses broad confidence across multiple domains but is only modestly related to domain-specific coping or behaviours. (Luszczynska et al., 2005).

Item Response Options

There were some concerns identified with the response options presented for each of the instruments. For example, concerns were raised about the clarity of the RAS, which uses a low to high response options (low=1, high=5) to measure satisfaction with their relationship with their child's other parent. Specifically, the participant was uncertain about how to select an answer on the provided response options to the question, “How often do you wish you hadn’t gotten into this relationship?” They questioned whether a score of 1 (low) meant that he does not want to leave the relationship, or does not regret the relationship, and if a score of 5 (high) indicates that he is happy in the relationship. The participant was also confused about the question, “How many problems are there in your relationship?” using the same low-high scale. They questioned whether a high score (5) means many problems or serious problems in the relationship, noting that “problems” could be interpreted in various ways, such as minor issues or disagreements over something such as household chores like cleaning the dishes, to more severe conflicts. To address the ambiguity, the participant suggested adding more specificity to the scale, such as defining what low and high represent (e.g., 1 = few or no problems, 5 = many problems) and clarifying the types of problems (e.g., minor disagreements versus major issues). Feedback highlighting the need for clearer definitions of “low” and “high,” and for distinguishing minor from major problems, reflects longstanding concerns in the questionnaire-design literature that vague response anchors can confuse respondents and produce inconsistent answers (Decastellarnau, 2018; Krosnick, 2018).

For the GSES instrument, a participant found the response option descriptors (not at all true, hardly true, moderately true, exactly true) to be vague, particularly because all options are framed using variations of true rather than a positive-negative scale (e.g., true-untrue), and the anchor, exactly true uses peculiar phrasing. The participant compared these response options to the PSOC which employs a Likert-type scale ranging from strongly disagree to strongly agree, noting that the latter was more straightforward and easier to understand.

Similarly, for the PPAS and its antenatal counterpart, the PAAS, concerns were expressed about the word choice in the response options, specifically regarding the use of the terms intense and moderate. One participant noted that intense felt too strong to describe their emotions, making them hesitant to select it, while the next option, moderate, did not accurately reflect their feelings either. Similarly, participants expressed confusion with the ordering of response options in the PSOC scale, which are strongly disagree, somewhat disagree, disagree, agree, somewhat agree, strongly agree. They suggested that the options are not in a logical sequence, noting that disagree suggests a stronger level of disagreement than somewhat disagree, and agree suggests a stronger level of agreement than somewhat agree. One participant questioned whether their confusion over the response ordering had led them to complete the entire survey incorrectly. They were unsure if their selected responses accurately reflected their intended answers. They reflected:

I'm not certain, but there was, and I just noticed this now and I could have possibly done the whole survey like this wrong. So, ‘agree’ was in the middle, ‘somewhat agree’, and then ‘strongly agree’ and I feel like ‘agree’ and ‘somewhat agree’ should have been switched. And the same with ‘disagree’ and ‘strongly or somewhat disagree’, it seems like the level should be from one to five and ‘agree’ seems stronger than ‘somewhat agree’.

The same participant expressed uncertainty about the question, “I sometimes feel like I’m not getting anything done” noting that they were unsure if selecting strongly agree meant they were actually not getting anything done or simply feeling like they were not getting anything done. Participants’ struggles with vague descriptors (e.g., “exactly true,” “intense”) and non-intuitive ordering of Likert options highlight the recurring issue in survey research of poorly designed anchors creating unnecessary cognitive load and risking inaccurate responses (Decastellarnau, 2018; Krosnick, 2018).

Cultural Safety

The participants provided insight into the cultural safety of the instruments. Although, overall, most instruments administered were thought to be culturally safe, a number of participants identified specific questions of concern about the EPDS's self-harm question: “The thought of harming myself has occurred to me.” Participants agreed upon its importance but emphasized its sensitivity. One participant expressed concern that the question might discourage honest responses due to fears of legal reporting obligations of the survey administrator, stating:

…having a bit of background in social work, the portion where it's asking if you want to harm yourself is an important question, but finding a different way because what you hear either as if you're running a program or partaking in it is, if you disclose something like that, the person may be legally obligated to have to report that in some kind of way. So that might make someone reluctant to respond truthfully.

Another participant highlighted the need for meaningful support for respondents who share thoughts of self-harm, questioning whether providing a list of resources constitutes due diligence. They recommended that a research team member directly contact the respondent to offer support themselves, connect the respondent with an Elder involved with the research project, or link them to an Indigenous Friendship Centre.

I think is an important one [self-harm question] to include when you're asking all the previous questions but making sure there's clear pathways for them to access services…If there is somebody or an Elder who's involved in the project that can be attached to that question so that the person can access that Elder, I think would be a great cultural follow-up way if somebody's feeling or having suicidal ideation.

A third participant suggested that respondents who have thoughts of self-harm “might really want to say something” and proposed adding an open-ended question to support respondents’ desires to share additional thoughts or concerns. Participants’ concerns about mandatory reporting, inadequate follow-up, and the absence of direct Elder support underscore calls in Indigenous health research for trauma-informed, culturally responsive safety protocols that go beyond resource lists to include immediate, relational care from community members (Alessi & Kahn, 2023; Brockie et al., 2022; Lalonde et al., 2020; Skewes et al., 2020).

Recommended Additions

Participants recommended adding questions to capture more detail about the Indigenous father's and Two-Spirit parent's relationship with their child. For example, one participant recommended adding a question about the types of activities Indigenous fathers and Two-Spirit parents engage in with their child. Another participant recommended a new question for the PPAS about the level of interest or affection respondents feel toward their baby/child, wondering whether there could be a meaningful connection between this affection and parental preparedness. The participant shared:

…it might be relevant in when you're asking fathers about their level of interest or affection that's being shown towards their child, maybe some reflection….I feel like there could be a correlation too, right? I feel like a lot of parents always want to give their child what they didn't have, you know? Or one of the questions at the end is like, “Do you feel that your father was as well prepared?” or something of that nature. And I feel like, no, it's the complete opposite. So, I feel like there might be some kind of correlation there with a question that kind of links, if you feel that you are more prepared then maybe that's why you show more affection or intensity in attention or affection towards your child….I feel like there could be a link there.

Participants also recommended the inclusion of questions that targeted supports for the Indigenous fathers and Two-Spirit parents. For example, one participant wanted a question added about the availability of support from family or friends during difficult times or when parents have work obligations. Another suggested adding a question to the RAS to examine whether respondents have considered or are currently in couples therapy when feeling unhappy or experiencing relationship problems. Financial circumstances were another area one participant wanted targeted on the instruments. The remaining recommendation was an opportunity for gathering further information from fathers. Several participants suggested adding comment boxes or spaces at the end of each instrument for respondents to share additional thoughts or concerns.

Instrument Revisions Based on Pretesting

Instrument pretesting resulted in many recommended revisions to the instruments. These revisions were discussed collaboratively among the Steering Committee, specifically the lead investigator and co-investigator overseeing the pretesting, and the research coordinator, a non- Steering Committee member. Proposed changes were then presented to the rest of the Steering Committee who provided no additional suggestions. The following modifications were made by consensus, with careful attention to preserving the psychometric integrity of the validated tool.

First, minor wording changes were made to simplify language on several tools. Original terminology was retained to preserve the psychometric properties of the instruments; however, clarifying terms were added in parentheses to support understanding. For example, the item from the GSES, “I am confident that I could deal efficiently with unexpected events,” was revised to “I am confident that I could deal efficiently (quickly) with unexpected events.” Similarly, the item “Over the past two weeks I have thought about, or been preoccupied with the developing baby” was changed to “Over the past two weeks I have thought about or been preoccupied with (thought a lot about) the developing (growing) baby.” Second, a new item was added to assess emotional wellness over a longer timeframe: “How would you rate your emotional wellness over the past 2 months?” with response options ranging from very happy to very sad. This revision was made in response to participant feedback that the EPDS's 7-day timeframe did not align with their lived experiences and could limit the accuracy of their responses. To improve the cultural safety of the instrument, the new item was introduced to better reflect Indigenous participants’ broader and more holistic understanding of emotional wellness. Third, participants acknowledged the importance of the EPDS self-harm item but expressed concern that the original wording might discourage respondents from answering truthfully. To preserve the instrument's psychometric properties, the original wording was retained; however, to ensure cultural safety and address potential distress, a message was added at both the beginning and end of the instrument, reassuring participants that the research team is concerned about their wellness and is available to provide support. The message also outlined the steps that would be taken if thoughts of self-harm were disclosed, including assessing the participant's immediate safety, linking the participant to personnel at a local Indigenous-led organization, and the research team's responsibility to involve emergency support services when appropriate. Fourth, to address concerns identified about the clarity of response options on the RAS, descriptors were added to the response anchors for each item in the RAS, as the meaning of “low” and “high” varied depending on the question. For example, for the item “How often do you wish you hadn’t gotten into this relationship?”, anchors were specified as 1 = never and 5 = very often. For the item “How many problems are there in your relationship?”, anchors were clarified as 1 = very few and 5 = many. See Table 2 for a summary of added anchor descriptors. Fifth, in response to the concerns about confusing response scale wording and ordering, the original PSOC scale was replaced with a revised version published by Gilmore and Cuskelly (2023). This updated tool, which became available after the study was initially designed, addresses several known limitations of the original scale, aligning with concerns raised by participants. The PSOC-R demonstrates good internal consistency (total scale Cronbach's alpha = .92), test-retest reliability (total scale r = .79, p < .001), construct validity (e.g., r = .72, p < .001 with Personal Accomplishment Scale; r = –.76, p < .001 with Parental Stress Scale), and criterion-related validity (MANOVA: F[6, 2434] = 6.215, p < .001, partial eta squared = .015), while staying true to the original construct (Gilmore & Cuskelly, 2023). Specifically, participants noted that terminology in the original PSOC, such as “preoccupied”, may hinder comprehension. The PSOC-R addresses this by reducing the reading level to a Flesch-Kincaid Grade level of 6.4 and simplifying items, such as splitting apart the double-barreled items. One participant found that the original PSOC's response scale confusing due to its illogical order (strongly disagree, somewhat disagree, disagree, agree, somewhat agree, strongly agree) and ambiguity of items (I sometimes feel like I’m not getting anything done). The PSOC-R resolves these issues by adopting a more intuitive Likert scale (i.e., strongly disagree, disagree, mildly disagree, mildly agree, agree, strongly agree) and rewording items positively, such as revising “I sometimes feel like I’m not getting anything done” highlighted by one participant as problematic to “I feel I am achieving my parenting goals,” ensuring clarity and accurate response interpretation (Gilmore & Cuskelly, 2023).

Table 2.

Relationship Assessment Scale (RAS) Adaptation.*

	Low				High
	1	2	3	4	5
How well does your partner meet your needs?	1 (not at all)	2	3	4	5 (very well)
In general, how satisfied are you with your relationship?	1 (not satisfied)	2	3	4	5 (very satisfied)
How good is your relationship compared to most?	1 (poor)	2	3	4	5 (excellent)
How often do you wish you hadn’t gotten into this relationship?	1 (never)	2	3	4	5 (very often)
To what extent has your relationship met your original expectations?	1 (not at all)	2	3	4	5 (completely)
How much do you love your partner?	1 (not much)	2	3	4	5 (a lot)
How many problems are there in your relationship?	1 (very few)	2	3	4	5 (many)

Note. Scale adapted from Hendrick (1988).

*Anchor descriptors were added to improve clarity.

Discussion

This study pretested six instruments—the Parenting Sense of Competence Scale (PSOC), Edinburgh Postnatal Depression Scale (EPDS), Relationship Assessment Scale (RAS), General Self-Efficacy Scale (GSES), Paternal Antenatal Attachment Scale (PAAS), and Paternal Postnatal Attachment Scale (PPAS)—among six First Nations and Métis fathers and Two-Spirit parents to assess clarity, comprehension, and cultural safety before Phase 3 of an Indigenous community-led study. Findings revealed challenges with challenging terminology, item response options, and cultural safety, which hindered accurate responses and prompted recommendations for improvement. Findings also suggest that the instruments do not sufficiently reflect a holistic view of wellness and parenting among Indigenous fathers and Two-Spirit parents, highlighting the need to refine these standardized tools.

Challenging Terminology

Challenging terminology was a key barrier to participants answering instrument questions. Abstract language often exceeded a fifth grade reading level, making questions difficult to answer confidently. Research shows that using plain language can improve data quality through fewer non-responses, more varied and thoughtful answers, fewer neutral responses, and higher over-time consistency (Bauer et al., 2023; Lenzner, 2012; Stallwood et al., 2023; Tumiel-Berhalter & Ortiz, 2024; Welbie et al., 2018). Participants also emphasized that plain language is particularly important for those facing literacy or engagement challenges (Bauer et al., 2023; Lenzner, 2012). Among Indigenous Peoples, plain language should use community-relevant wording and avoid academic jargon (Brockie et al., 2022; Le Grande et al., 2017; Maar et al., 2011).

Addressing terminology challenges goes beyond simpler words. Euro-Western literacy focuses on reading, writing and using numeracy (UNESCO, 2025), whereas many Indigenous perspectives of literacy view literacy holistically, integrating oral, visual, experiential, and spiritual knowledge (Ontario Native Literacy Coalition, n.d.). Because of this difference, non-Indigenous instruments require refinement beyond plain language to ensure that concepts such as wellness, depression, and self-efficacy align with Indigenous understandings and that instruments are developed and delivered in culturally relevant ways reflecting Indigenous Peoples’ holistic perspectives of literacy (Martinez, 2023; Rose, 2016). For instance, Euro-Western instruments assessing constructs like depression, often employ individual, text-based responses, whereas Indigenous literacy principles may emphasize talking or sharing circles, necessitating tools that accommodate different modalities (Brockie et al., 2022; Chan et al., 2021; Le Grande et al., 2017). In their review of 33 studies, Le Grande et al. (2017) found that standard instruments often lack relevance without adaptation, while Indigenous-developed measures better reflect many Australian Indigenous holistic frameworks of wellness. They recommended using Euro-Western instruments only after formal cross-cultural adaptation. Without adaptation, Euro-Western instruments risk perpetuating cultural disconnects and reducing data validity, further alienating Indigenous participants who are already wary of research (Brockie et al., 2022; Chan et al., 2021; Le Grande et al., 2017; Skewes et al., 2020). Researchers should therefore co-design tools with Indigenous communities (e.g., see McCalman et al., 2017) to ensure alignment with community literacy frameworks and integrate plain language into culturally relevant measures. Where co-design is not feasible, formal cross-cultural adaptation and complimentary qualitative methods can strengthen accessibility and cultural relevance (Borsa et al., 2012; Cardona et al., 2023; Gjersing et al., 2010; Schmidt & Bullinger, 2003).

Item Response Challenges

Participants experienced confusion with response scales and their descriptors, which sometimes led to unintended interpretations. The RAS low-to-high scale (1 = low, 5 = high) illustrates this issue. The “low” and “high” may be understood differently depending on the question, as the ambiguity of the scale anchors require respondents to assign differential meaning depending on the question. In, “How well does your partner meet your needs?”, low may mean “not well” and high “very well”. However, in the later question “How often do you wish you hadn’t gotten into this relationship?” the same low-to-high anchors do not fit the frequency-based question. This inconsistency forces respondents to infer meaning, increasing the likelihood of misinterpretation (Choi & Pak, 2005; Decastellarnau, 2018). Similarly, the PSOC's response options (strongly disagree, somewhat disagree, disagree, agree, somewhat agree, strongly agree) also caused confusion. Some participants noted disagree appeared stronger than somewhat disagree (and the same with the positive end of the scale), disrupting the logical order and increasing cognitive burden, potentially reducing response accuracy (Choi & Pak, 2005; Krosnick, 2018). Volante et al. (2018) found similar discrepancies, with participants interpreting positively worded anchors as stronger and unevenly spaced. These findings resonate with observations from our study regarding the item response option intense affection to the question, “Over the last two weeks I would describe my feelings for the baby as:” with response options ranging from dislike to intense affection. One participant noted that intense affection felt overly strong for their experiences, yet the next option, moderate affection, did not accurately fit the participant's feelings on the positive end of the scale, suggesting a misalignment between the scale's item responses and respondents’ actual feelings or experiences. When using these tools with Indigenous communities, scholars advocate for tailored response scales, such as visual analogue scales (e.g., Dowsett et al., 2019), tailored or translated questions (Dowsett et al., 2019; Maar et al., 2011), and community developed or adapted instruments (Le Grande et al., 2017) to enhance cultural relevance and therefore, understanding and relevance to Indigenous participants.

Cultural Alignment and Safety Challenges

Study findings revealed a misalignment between Euro-Western and many Indigenous perspectives on wellness, including how depression is understood and measured. Participants suggested refining instruments to capture their experiences more accurately, including questions on their financial situation, a deeper exploration of their relationship with their partner, activities they engage in with their children, support from family or friends, and coping strategies across life situations. They also recommended assessing emotional wellness over a longer time than the 7-day period on the EPDS, exploring the concept of ‘low feelings’ beyond sadness, and including open-ended responses. These suggestions reflect a holistic understanding of wellness that spans physical, mental, social, cultural, spiritual, familial, community, traditional medicines, and connection to land (Gee et al., 2014; Hall et al., 2020; Hill, 2009; Le Grande et al., 2017; Ponnapalli et al., 2023; Thiessen et al., 2020; Tsuji et al., 2023). Hill (2009) notes that wellness in Indigenous communities is founded on the interconnection of land, language, and culture. Ponnapalli et al. (2023) observed that many Aboriginal or Torres Strait Islander parents integrate culture, land, and spirituality across child, parent, and community domains, intertwining their own wellbeing with their children's and broader context, in contrast to Euro-Western psychosocial indicators like depression that focus on the individual rather than relational and collective wellness (Ponnapalli et al., 2023; Tsuji et al., 2023).

The EPDS's 7-day timeframe for postnatal depression further demonstrates this Euro-Western bias, as biomedical models assume depression risk can be captured through individual-focused questions over a brief period. However, study findings reveal this one-week assessment of low feelings inadequately reflects depression and mental wellness among participants, whose holistic understanding of wellness includes multiple factors that exist over a much longer time frame, such as the impact of colonization and resulting intergenerational trauma (Chan et al., 2021; Gee et al., 2014; Hall et al., 2020; Kirmayer et al., 2000; Le Grande et al., 2017). One participant notes that the 7-day timeframe failed to reflect their emotions and suggested a 6–12-month frame or an additional question to capture overall mental and emotional wellness. Other research supports this, showing Indigenous perspectives on depression often weave spiritual, emotional, physical, and social elements (Brown, 2009; Brown et al., 2012; Cain et al., 2011; Kirmayer et al., 2000). For example, Indigenous men in Central Australia describe depression through Kurunpa (spirit), worry, and balance (Brown, 2009). In Canada, many Indigenous Peoples link depression to isolation, racism, and trauma (Cain et al., 2011) viewing mental wellness as inclusive of relationality and connectedness (balance and connection, community, Elders and family, social contribution, meaning and purpose, spirituality, connection to the land, history and stories, traditional teachings, language, belonging, identity, and stability), coming together to maintain harmony and health (Kyoon-Achan et al., 2018). Across these communities, depression is connected to colonial legacies, as colonization has disrupted relationality and connectedness, which are key components of wellness among Indigenous Peoples. This disruption has contributed to cultural discontinuity and increased vulnerability to depression (Kirmayer et al., 2000).

The EPDS self-harm indicator further highlights the individualized focus of Euro-Western tools compared to Indigenous frameworks of wellness. While the EPDS isolates symptoms like suicidal thoughts within the individual, Indigenous models such as the Social and Emotional Wellbeing (SEWB) framework for Aboriginal and Torres Strait Islander Peoples, prioritize collective wellness across individual, family, and community dimensions, integrating cultural resilience, connection to land (Country), and the impacts of colonization (Ciocca et al., 2017; Dudgeon et al., 2014). This contrast underscores the need for research tools that reflect Indigenous understandings of depression and wellness and account for how systemic factors like intergenerational trauma shape experiences (Hall et al., 2020).

Participants also raised concerns about cultural safety and ethics, particularly around the EPDS self-harm question. Mandatory reporting obligations could discourage honest responses due to fear of legal consequences, a frequent experience in many Indigenous communities (Blackstock et al., 2004; Leckey et al., 2022). Participants recommended culturally responsible follow-up actions, including direct outreach, Elder involvement, referrals to Indigenous-specific support services, and open-ended questions to support meaningful expression. These concerns reflect a long history of research-related exploitation and harm within Indigenous communities (Brockie et al., 2022; Maar et al., 2011; Tamlyn et al., 2023).

These insights emphasize the need for researchers to adopt a relational and community-based approach and to be responsible for participants’ wellbeing. Participants should be fully informed of risks and supported in culturally safe ways, which requires community knowledge of relevant protocols. Simply involving emergency supports is not adequate in most cases. Instead, Indigenous participants should be immediately connected to culturally relevant social support networks who have staff equipped with the knowledge and skills to assess and support these individuals. For Phase 3 of our study, the Steering Committee will connect any participant at risk with the closest Indigenous-led organization equipped to provide culturally safe support using culturally responsive referral pathways, as recommended by Dudgeon et al. (2020). Kinship care models as described by Leckning et al. (2021) and Kickett et al. (2019), also illustrate culturally informed arrangements supporting Indigenous children and their families, including kinship carers such as fathers that prioritize family and community connections to address trauma and self-harm in culturally responsive ways. Collectively, these examples demonstrate the need to move beyond Euro-Western measurement instruments toward trauma-informed, culturally safe, and community-driven research practices that reflect Indigenous understandings of wellness and depression and account for historical experiences like colonization and intergenerational trauma (Alessi & Kahn, 2023; Gee et al., 2014; Knowledge Hub, 2024; Lalonde et al., 2020; Le Grande et al., 2017; Straatman & Baker, 2022).

Including financial questions is relevant to fatherhood and parenting roles (Reilly & Rees, 2018), but care is needed, as such questions may feel intrusive or culturally unsafe (Maar et al., 2011). Sensitive framing (e.g., “How does your financial situation support your family's wellness?”), thoughtful placement, and establishing rapport and trust with participants can help balance relevance and safety (Cidro et al., 2017; Maar et al., 2011; Oster & Lightning, 2022; Skewes et al., 2020). Overall, culturally aligned instruments must centre cultural safety and relational ethics, ensuring that data collection supports participants and is respectful and culturally safe.

Implications for Nursing

Findings from this study offer three key implications for nursing. First, they highlight the necessity of pretesting Euro-Western instruments with Indigenous participants to ensure cultural safety and measurement accuracy (Brockie et al., 2022; Chan et al., 2021; Clarke, 2008). Nurse researchers should not assume psychometric robustness means appropriateness or accuracy among Indigenous research participants, and instead make efforts to ensure Euro-Western instruments undergo a formal cross-cultural adaptation process (Le Grande et al., 2017), or partner with the Indigenous community to lead the development of new instruments (Gerlach et al., 2017; Le Grande et al., 2017). Second, the identified need for plain language, sensitivity around mental health and suicide questions, and immediate support pathways to Elders or Indigenous-specific supports underscores the importance of trauma- and violence-informed approaches to research, as well as to the training of nurse researchers (Alessi & Kahn, 2023; Lalonde et al., 2020). Third, in clinical practice, nurses can advocate for the use of flexible, culturally responsive assessment tools for Indigenous parents and direct referral pathways to support parents when needed (Cidro et al., 2017; Gerlach et al., 2017; Thiessen et al., 2020).

Study Limitations

This study has several limitations. First, the sample size was small, with six participants representing First Nations and Métis cultures. This limits the diversity of perspectives across Indigenous communities and Nations, and Indigenous fathers and Two-Spirit parents, and more expansive testing can be done to ensure the scales are appropriate across many diverse Indigenous cultures (Patel-Syed et al., 2024; Willis, 1999; Willis, 2005). Second, five of the six participants had previously participated in Phase 1, making them familiar with the research team and project purpose. This prior involvement may have influenced participants’ responses, as they may have been more comfortable with the project and research team. Consequently, Indigenous fathers and Two-Spirit parents who are less connected to services or hesitant about research may be underrepresented, particularly on issues like cultural safety and trust. Third, the study pretested Euro-Western instruments that, despite consultation with the Indigenous-led Steering Committee and refinement, retain cultural biases. Their design does not fully reflect Indigenous worldviews or holistic concepts of wellness, such as connections to land, spirituality, or community. To address this, the Steering Committee added new questions in addition to the instruments and will invite Indigenous fathers and Two-Spirit parents to participate in Phase 3 interviews to explore experiences and feedback in more depth, allowing discussion of topics not captured by the surveys.

Conclusion

This study pretested six wellness instruments—Parenting Sense of Competence Scale, Edinburgh Postnatal Depression Scale, Relationship Assessment Scale, General Self-Efficacy Scale, Paternal Antenatal Attachment Scale, and Paternal Postnatal Attachment Scale —with First Nations and Métis fathers and Two-Spirit parents to assess clarity, comprehensibility, and cultural appropriateness for a community-engaged parenting study. Results identified challenges to accurate wellness assessment, including challenging terminology, unclear item response descriptors, cultural misalignment, and cultural safety concerns. These issues prompted refinements such as plain language, intuitive scale anchors, and open-ended questions to capture additional insights. While these revisions enhanced cultural relevance and usability, the instruments will undergo psychometric testing in Phase 3 before they can be recommended for broad use with Indigenous fathers and Two-Spirit parents. The instruments’ Euro-Western conceptualization of wellness contrasts with many Indigenous perspectives, which include mental, emotional, physical, social, and spiritual dimensions. This misalignment highlights the limitations of “standard” tools in capturing wellness among Indigenous participants. At a minimum, wellness scales should be adapted to align with traditional Indigenous understandings and knowledge systems. Finally, this study underscores an ethical imperative for researchers to ensure participants’ wellness, including collaboration with local community partners to maintain cultural safety protocols for those who are participating in research.

Footnotes

Acknowledgments

We thank the fathers, Two-Spirit parents, Knowledge Holders, service providers, and Indigenous-led community partners — Hamilton Regional Indian Centre, Indigenous Diabetes Health Circle, Six Nations Birthing Centre, and Six Nations Social Services — who contributed to this study, as well as the Fathers of the Next Generation Steering Committee for their insightful guidance.

ORCID iDs

Michelle L. Butt

Nicole Goodfellow

Stephanie D. George

Amy L. Wright

Ethics Considerations

This study received ethics approval from the University of Toronto Research Ethics Board [#44860] and the Six Nations of the Grand River Research Ethics Committee.

Consent to Participate

All participants provided informed verbal or written consent prior to participation.

Consent for Publication

Permission granted from the Six Nations of the Grand River Research Ethics Board

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Canadian Institutes of Health Research Indigenous Gender and Wellness Team Grant [grant number 179317].

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability

The data that support the findings of this study are not publicly available due to community ownership of data (First Nations Information Governance Centre, 2025).

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Pretesting Parenting Instruments with Indigenous Fathers and Two-Spirit Parents: A Qualitative Study

Abstract

Background and Purpose

Methods and Procedures

Results

Conclusion

Keywords

Background and Purpose

Methods and Procedures

Guiding Frameworks

Study Design

Instruments – Selection and Description

Sampling and Recruitment

Data Collection

Data Analysis

Authors’ Positionality

Results

Comprehension of Instrument Instructions, Terminology, and Questions

Item Response Options

Cultural Safety

Recommended Additions

Instrument Revisions Based on Pretesting

Discussion

Challenging Terminology

Item Response Challenges

Cultural Alignment and Safety Challenges

Implications for Nursing

Study Limitations

Conclusion

Footnotes

Acknowledgments

ORCID iDs

Ethics Considerations

Consent to Participate

Consent for Publication

Funding

Declaration of Conflicting Interests

Data Availability

References