Community development through partnership: promoting health in an urban indigenous community in New Zealand

Effects of lifestyle interventions on weight amongst Pasifika communities: A systematic review and meta-analysis

BACKGROUND

Pasifika populations experience high incidence and prevalence of obesity and T2DM. However, no international review of lifestyle intervention studies amongst Pasifika communities exists. This study seeks to identify the effect and translatability of lifestyle strategies on weight amongst Pasifika populations.

METHODS

Lifestyle studies involving ≥90% adult Pasifika participants measuring weight change were eligible for inclusion. Database searching was carried out up to December 2021. Databases searched were MEDLINE (Ovid), EMBASE (Ovid), CINAHL (EBSCOhost) and ProQuest Central. Risk of bias was assessed using RoB2 (RCTs) and the National Heart, Lung and Blood Institute (NHLBI) quality assessment tool. Meta-analysis and meta-regression used a bivariate random-effects model. Strategies were coded against pre-identified components of the newly proposed Cultural and Sustainability Assessment of Intervention (CSAI) framework.

FINDINGS

Twenty-three studies (n = 4258 participants) met inclusion and exclusion criteria. Thirty-two lifestyle strategies targeting weight loss (WL) and 7 targeting weight maintenance (WM) were extracted. Meta-analysis estimates small but significant effect of -0.26 standard deviations (95% CI -0.51 to -0.02), with RCTs demonstrating a non-significant effect of -0.23 standard deviations (95% CI -0.49 to 0.035). Culturally relevant strategies included community and peer support facilitators and team-based activities. The CSAI identified 14 out of 23 studies with low cultural competency and sustainability scores (<60%).

INTERPRETATION

Qualitative and quantitative analysis show tailored lifestyle interventions has had an estimated small but beneficial effect on WL amongst Pasifika communities. Potential for tailored interventions design to incorporate psychosocial and behavioural considerations. The CSAI has the potential for systematically identifying cultural and sustainability components of efficacy in interventions.

FUNDING

This review was funded under Western Sydney University's Postgraduate Research Scholarship.

Using Community Based Research Frameworks to Develop and Implement a Church-Based Program to Prevent Diabetes and Its Complications for Samoan Communities in South Western Sydney

Pasifika communities bear a disproportionate burden of diabetes compared to the general Australian population. Community-based participatory research (CBPR), which involves working in partnership with researchers and communities to address local health needs, has gained prominence as a model of working with underserved communities. This paper describes how Le Taeao Afua (LTA) Samoan diabetes prevention program was underpinned by two CBPR frameworks to develop a culturally tailored church-based lifestyle intervention to prevent diabetes and its complications in the Australian Samoan community. The name LTA, which means ‘a new dawn,’ was chosen by the community to signify a new dawn without diabetes in the Australian Samoan community. Strategies for engaging with the Australian Samoan community in South Western Sydney are discussed mapped to the key principles from the CBPR frameworks. In particular, this paper highlights the steps involved in building relationships with Samoan community leaders and the vital role of community activators and peer support facilitators in the success of delivering the program. Lessons learnt, such as the importance of church and maintaining a Samoan way of life in daily activities, and processes to build effective partnerships and maintain long-term relationships with the Australian Samoan community, are also discussed. Our paper, through providing a case example of how to apply CBPR frameworks, will help guide future community-based health promotion programs for underserved communities.

Community engagement approaches for Indigenous health research: recommendations based on an integrative review

OBJECTIVE

Community engagement practices in Indigenous health research are promoted as a means of decolonising research, but there is no comprehensive synthesis of approaches in the literature. Our aim was to assemble and qualitatively synthesise a comprehensive list of actionable recommendations to enhance community engagement practices with Indigenous peoples in Canada, the USA, Australia and New Zealand.

DESIGN

Integrative review of the literature in medical (Medline, Cumulative Index to Nursing and Allied Health Literature and Embase) and Google and WHO databases (search cut-off date 21 July 2020).

ARTICLE SELECTION

Studies that contained details regarding Indigenous community engagement frameworks, principles or practices in the field of health were included, with exclusion of non-English publications. Two reviewers independently screened the articles in duplicate and reviewed full-text articles.

ANALYSIS

Recommendations for community engagement approaches were extracted and thematically synthesised through content analysis.

RESULTS

A total of 63 studies were included in the review, with 1345 individual recommendations extracted. These were synthesised into a list of 37 recommendations for community engagement approaches in Indigenous health research, categorised by stage of research. In addition, activities applicable to all phases of research were identified: partnership and trust building and active reflection.

CONCLUSIONS

We provide a comprehensive list of recommendations for Indigenous community engagement approaches in health research. A limitation of this review is that it may not address all aspects applicable to specific Indigenous community settings and contexts. We encourage anyone who does research with Indigenous communities to reflect on their practices, encouraging changes in research processes that are strengths based.

Outcomes of a church-based lifestyle intervention among Australian Samoans in Sydney - Le Taeao Afua diabetes prevention program

AIMS

To evaluate the effectiveness of a culturally adapted, church-based lifestyle intervention among Australian Samoans living in Sydney.

METHODS

This was a prospective, pre-post study of a church-wide education and support programme delivered by Community Coach Facilitators and Peer Support Facilitators to prevent, and promote self-management of, Type 2 diabetes. Participants completed questionnaires, anthropometric and HbA1c measurements before and 3-8 months after the intervention. The primary outcome was HbA1c.

RESULTS

Overall, 68/107(63.5%) participants completed both before and after intervention data collection (mean age 48.9 ± 14.2 years; 57.2% female). HbA1c dropped significantly between baseline and follow-up among participants with known diabetes (8.1 ± 2.4% (65 mmol/mol) vs 7.4 ± 1.8% (57 mmol/mol); p = 0.040) and non-significantly among participants with newly diagnosed diabetes (8.0 ± 2.1% (64 mmol/mol) vs 7.1 ± 2.3 (54 mmol/mol); p = 0.131). Participants with no diabetes increased their weekly moderate and vigorous physical activity (316.1 ± 291.6mins vs 562.4 ± 486.6mins; p = 0.007) and their diabetes knowledge also improved post-intervention (42.0 ± 13.5% to 61.3 ± 20.2%; p < 0.001). There were no significant reductions in blood pressure, BMI or waist circumference at follow-up.

CONCLUSIONS

A structured, church-based, culturally tailored lifestyle intervention showed a number of improvements in diabetes risk among Samoans in Sydney. The intervention however, requires a more rigorous testing in a larger randomised controlled trial over a longer time period.

Social contributors to cardiometabolic diseases in indigenous populations: an international Delphi study

OBJECTIVE

The objective of this study was to identify priority social factors contributing to indigenous cardiometabolic diseases.

STUDY DESIGN

A three-round Delphi process was used to consolidate and compare the opinions of 60 experts in indigenous cardiometabolic health from Australia, New Zealand and the United States.

METHODS

Round one: three open-ended questions: (i) historical, (ii) economic and (iii) sociocultural factor contributors to cardiometabolic disease risk. Round two: a structured questionnaire based on the results from the first round; items were ranked according to perceived importance. Final round: the items were reranked after receiving the summary feedback.

RESULTS

Several key findings were identified: (i) an important historical factor is marginalisation and disempowerment; (ii) in terms of economic and sociocultural factors, the panellists came to the consensus that the socio-economic status and educational inequalities are important; and (iii) while consensus was not reached, economic and educational factors were also perceived to be historically influential.

CONCLUSION

These findings support the need for multilevel health promotion policy. For example, tackling financial barriers that limit the access to health-promoting resources, combined with improving literacy skills to permit understanding of health education.

Experiences of health service providers establishing an Aboriginal-Mainstream partnership to improve maternity care for Aboriginal and Torres Strait Islander families in an urban setting

Australian policy encourages multiagency partnerships between hospitals and Aboriginal Community Controlled Health Organisations to improve the health of Aboriginal and Torres Strait Islander people. Service planners remain unsure about how to implement such partnerships in maternity care, and there is a lack of appropriate tools designed to gauge the state of such partnerships for the Australian Indigenous context. In 2013, two Aboriginal health services and a major tertiary hospital partnered to deliver best practice maternity care to Indigenous families in Brisbane, Australia. A participatory action research approach underpinned this study. Semi-structured qualitative interviews and focus groups were conducted with 21 of the partnership staff. All interviewees emphasized the partnership's commitment to improving long-term health and wellbeing for Indigenous families. Strategic planners were more likely to report a positive partnership than staff involved in service delivery who had diverse views. This highlights the challenges of change management when conducting such a significant service redesign in this cross-cultural context. We detail changes made within the partnership in response to the findings and provide suggestions for future development of an evaluation tool to review the state of Aboriginal-Mainstream Partnerships.

A Qualitative Exploration of Fijian Perceptions of Diabetes: Identifying Opportunities for Prevention and Management

Rates of diabetes are high in many communities of Pacific Island peoples, including people from Fiji. This qualitative study explores knowledge and attitudes towards diabetes among i-Taukei Fijians to facilitate the cultural tailoring of diabetes prevention and management programs for this community. Fijians aged 26 to 71 years (n = 15), residing in Australia, participated in semi-structured interviews; 53% (n = 8) were male. Interviews were audio-recorded, transcribed verbatim, then thematically analyzed. Diabetes is recognized as an important and increasing health problem requiring action in the i-Taukei Fijian community. Widespread support for culturally appropriate lifestyle interventions utilizing existing societal structures, like family networks and church groups, was apparent. These structures were also seen as a crucial motivator for health action. Intervention content suggestions included diabetes risk awareness and education, as well as skills development to improve lifestyle behaviors. Leveraging existing social structures and both faith and family experiences of diabetes within the Fijian community may help convert increased awareness and understanding into lifestyle change. Ongoing in-community support to prevent and manage diabetes was also regarded as important. We recommend building upon experience from prior community-based interventions in other high-risk populations, alongside our findings, to assist in developing tailored diabetes programs for Fijians.

Black and minority ethnic group involvement in health and social care research: A systematic review

BACKGROUND

Patient and public involvement (PPI) in research is growing internationally, but little is known about black and minority ethnic (BME) involvement and the factors influencing their involvement in health and social care research.

OBJECTIVES

To characterize and critique the empirical literature on BME-PPI involvement in health and social care research.

SEARCH STRATEGY

Systematic searches of six electronic bibliographic databases were undertaken, utilizing both MeSH and free-text terms to identify international empirical literature published between 1990 and 2016.

INCLUSION CRITERIA

All study designs that report primary data that involved BME groups in health or social care research. Screening was conducted by two reviewers.

DATA EXTRACTION AND SYNTHESIS

Data extraction and quality appraisal were performed independently. Data extraction focused on the level(s) of PPI involvement and where PPI activity occurred in the research cycle. Studies were quality-assessed using the guidelines for measuring the quality and impact of user involvement in research. Data were analysed using a narrative approach.

MAIN RESULTS

Forty-five studies were included with the majority undertaken in the USA focusing on African Americans and indigenous populations. Involvement most commonly occurred during the research design phase and least in data analysis and interpretation.

CONCLUSION

This is the first systematic review investigating BME involvement in health and social care research internationally. While there is a widespread support for BME involvement, this is limited to particular phases of the research and particular ethnic subgroups. There is a need to understand factors that influence BME involvement in all parts of the research cycle.

Yarning about fall prevention: community consultation to discuss falls and appropriate approaches to fall prevention with older Aboriginal and Torres Strait Islander people

Background

Fall related injury is an emerging issue for older Indigenous people worldwide, yet few targeted fall prevention programs are currently available for Indigenous populations. In order to inform the development of a new Aboriginal-specific fall prevention program in Australia, we conducted community consultation with older Aboriginal people to identify perceptions and beliefs about falls, and to identify desired program elements.

Methods

Yarning Circles were held with Aboriginal and Torres Strait Islander people aged 45 years and over. Each Yarning Circle was facilitated by an Aboriginal researcher who incorporated six indicative questions into each discussion. Questions explored the impact of falls on Yarning Circle participants, their current use of fall prevention services and investigated Yarning Circle participant’s preferences regarding the design and mode of delivery of a fall prevention program.

Results

A total of 76 older Aboriginal people participated in ten Yarning Circles across six sites in the state of New South Wales. Participants associated falls with physical disability, a loss of emotional well-being and loss of connection to family and community. Many participants did not use existing fall prevention services due to a lack of availability in their area, having no referral provided by their GP and/or being unaware of fall prevention programs in general. Program elements identified as important by participants were that it be Aboriginal-specific, group-based, and on-going, with the flexibility to be tailored to specific communities, with free transport provided to and from the program.

Conclusions

Older Aboriginal people reported falls to be a priority health issue, with a significant impact on their health and well-being. Few older Aboriginal people accessed prevention programs, suggesting there is an important need for targeted Aboriginal-specific programs. A number of important program elements were identified which if incorporated into prevention programs, may help to address the rising burden of falls.

Principles and strategies for improving the prevention of cardio-metabolic diseases in indigenous populations: An international Delphi study

The disparity in life expectancy between Indigenous and non-Indigenous populations, including within high-income countries, is driven by a heightened risk of cardio-metabolic diseases. The current study recruited independent panels of experts in Indigenous cardio-metabolic health from Australia, New Zealand and the United States, in order to establish local consensus opinion and initiate dialogue on appropriate prevention strategies. Therefore, a three-round Delphi process was used to consolidate and compare the opinions of 60 experts, 20 from each country. Round one, the experts were asked twelve open-ended questions across six domains: (i) prevention; (ii) consultation; (iii) educational resources; (iv) societal issues; (v) workforce issues; (vi) culture and family. Round two, the experts completed a structured questionnaire based on results from the first round, in which they ranked items according to their importance. Final round, the experts were asked to re-rank the same items after receiving summary feedback about the rank ordering from the previous round. Several themes emerged common to all three countries: (i) socio-economic and education inequalities should be addressed; (ii) educational, behaviour change and prevention strategies should address physical environmental determinants and be responsive to the local context, including being culturally appropriate; and (iii) cultural appropriateness can be achieved through consultation with Indigenous communities, cultural competency training, use of Indigenous health workers, and use of appropriate role models. These findings highlight several key priorities that can be used to initiate dialogue on appropriate prevention strategies. Such strategies should be contextualized to the local Indigenous populations.

An exploration of inter-organisational partnership assessment tools in the context of Australian Aboriginal-mainstream partnerships: a scoping review of the literature

Background

The need for better partnerships between Aboriginal organisations and mainstream agencies demands attention on process and relational elements of these partnerships, and improving partnership functioning through transformative or iterative evaluation procedures. This paper presents the findings of a literature review which examines the usefulness of existing partnership tools to the Australian Aboriginal-mainstream partnership (AMP) context.

Methods

Three sets of best practice principles for successful AMP were selected based on authors’ knowledge and experience. Items in each set of principles were separated into process and relational elements and used to guide the analysis of partnership assessment tools. The review and analysis of partnership assessment tools were conducted in three distinct but related parts. Part 1- identify and select reviews of partnership tools; part 2 – identify and select partnership self-assessment tool; part 3 – analysis of selected tools using AMP principles.

Results

The focus on relational and process elements in the partnership tools reviewed is consistent with the focus of Australian AMP principles by reconciliation advocates; however, historical context, lived experience, cultural context and approaches of Australian Aboriginal people represent key deficiencies in the tools reviewed. The overall assessment indicated that the New York Partnership Self-Assessment Tool and the VicHealth Partnership Analysis Tools reflect the greatest number of AMP principles followed by the Nuffield Partnership Assessment Tool. The New York PSAT has the strongest alignment with the relational elements while VicHealth and Nuffield tools showed greatest alignment with the process elements in the chosen AMP principles.

Conclusions

Partnership tools offer opportunities for providing evidence based support to partnership development. The multiplicity of tools in existence and the reported uniqueness of each partnership, mean the development of a generic partnership analysis for AMP may not be a viable option for future effort.

Should the governments of 'developed' countries be held responsible for equalizing the indigenous health gap?

Across the globe there is significant variation between and within indigenous populations in terms of world view, culture, and socio-political forces. However, many indigenous groups do share a striking commonality: greater rates of non-communicable diseases and shorter life expectancies than non-indigenous compatriots. Notably, this health gap persists for 'developed' countries, including Australia, Canada, New Zealand and the United States. The question of who is responsible for equalizing the gap is complicated. Using Australia as an exemplar context, this commentary will present arguments 'for' and 'against' the governments of developed nations being held liable for closing the indigenous health gap. We will discuss the history and nature of the health gap, actions needed to 'close the gap', and which party has the necessary resources to do so.

Community wide interventions for increasing physical activity

BACKGROUND

Multi-strategic community wide interventions for physical activity are increasingly popular but their ability to achieve population level improvements is unknown.

OBJECTIVES

To evaluate the effects of community wide, multi-strategic interventions upon population levels of physical activity.

SEARCH METHODS

We searched the Cochrane Public Health Group Segment of the Cochrane Register of Studies,The Cochrane Library, MEDLINE, MEDLINE in Process, EMBASE, CINAHL, LILACS, PsycINFO, ASSIA, the British Nursing Index, Chinese CNKI databases, EPPI Centre (DoPHER, TRoPHI), ERIC, HMIC, Sociological Abstracts, SPORT Discus, Transport Database and Web of Science (Science Citation Index, Social Sciences Citation Index, Conference Proceedings Citation Index). We also scanned websites of the EU Platform on Diet, Physical Activity and Health; Health-Evidence.org; the International Union for Health Promotion and Education; the NIHR Coordinating Centre for Health Technology (NCCHTA); the US Centre for Disease Control and Prevention (CDC) and NICE and SIGN guidelines. Reference lists of all relevant systematic reviews, guidelines and primary studies were searched and we contacted experts in the field. The searches were updated to 16 January 2014, unrestricted by language or publication status.

SELECTION CRITERIA

Cluster randomised controlled trials, randomised controlled trials, quasi-experimental designs which used a control population for comparison, interrupted time-series studies, and prospective controlled cohort studies were included. Only studies with a minimum six-month follow up from the start of the intervention to measurement of outcomes were included. Community wide interventions had to comprise at least two broad strategies aimed at physical activity for the whole population. Studies which randomised individuals from the same community were excluded.

DATA COLLECTION AND ANALYSIS

At least two review authors independently extracted the data and assessed the risk of bias. Each study was assessed for the setting, the number of included components and their intensity. The primary outcome measures were grouped according to whether they were dichotomous (per cent physically active, per cent physically active during leisure time, and per cent physically inactive) or continuous (leisure time physical activity time (time spent)), walking (time spent), energy expenditure (as metabolic equivalents or METS)). For dichotomous measures we calculated the unadjusted and adjusted risk difference, and the unadjusted and adjusted relative risk. For continuous measures we calculated percentage change from baseline, unadjusted and adjusted.

MAIN RESULTS

After the selection process had been completed, 33 studies were included. A total of 267 communities were included in the review (populations between 500 and 1.9 million). Of the included studies, 25 were set in high income countries and eight were in low income countries. The interventions varied by the number of strategies included and their intensity. Almost all of the interventions included a component of building partnerships with local governments or non-governmental organisations (NGOs) (29 studies). None of the studies provided results by socio-economic disadvantage or other markers of equity. However, of those included studies undertaken in high income countries, 14 studies were described as being provided to deprived, disadvantaged or low socio-economic communities. Nineteen studies were identified as having a high risk of bias, 10 studies were unclear, and four studies had a low risk of bias. Selection bias was a major concern with these studies, with only five studies using randomisation to allocate communities. Four studies were judged as being at low risk of selection bias although 19 studies were considered to have an unclear risk of bias. Twelve studies had a high risk of detection bias, 13 an unclear risk and four a low risk of bias. Generally, the better designed studies showed no improvement in the primary outcome measure of physical activity at a population level.All four of the newly included, and judged to be at low risk of bias, studies (conducted in Japan, United Kingdom and USA) used randomisation to allocate the intervention to the communities. Three studies used a cluster randomised design and one study used a stepped wedge design. The approach to measuring the primary outcome of physical activity was better in these four studies than in many of the earlier studies. One study obtained objective population representative measurements of physical activity by accelerometers, while the remaining three low-risk studies used validated self-reported measures. The study using accelerometry, conducted in low income, high crime communities of USA, emphasised social marketing, partnership with police and environmental improvements. No change in the seven-day average daily minutes of moderate to vigorous physical activity was observed during the two years of operation. Some program level effect was observed with more people walking in the intervention community, however this result was not evident in the whole community. Similarly, the two studies conducted in the United Kingdom (one in rural villages and the other in urban London; both using communication, partnership and environmental strategies) found no improvement in the mean levels of energy expenditure per person per week, measured from one to four years from baseline. None of the three low risk studies reporting a dichotomous outcome of physical activity found improvements associated with the intervention.Overall, there was a noticeable absence of reporting of benefit in physical activity for community wide interventions in the included studies. However, as a group, the interventions undertaken in China appeared to have the greatest possibility of success with high participation rates reported. Reporting bias was evident with two studies failing to report physical activity measured at follow up. No adverse events were reported.The data pertaining to cost and sustainability of the interventions were limited and varied.

AUTHORS' CONCLUSIONS

Although numerous studies have been undertaken, there is a noticeable inconsistency of the findings in the available studies and this is confounded by serious methodological issues within the included studies. The body of evidence in this review does not support the hypothesis that the multi-component community wide interventions studied effectively increased physical activity for the population, although some studies with environmental components observed more people walking.

Examining the potential contribution of social theory to developing and supporting Australian Indigenous-mainstream health service partnerships

Introduction

The substantial gap in life expectancy between Indigenous and non-Indigenous Australians has been slow to improve, despite increased dedicated funding. Partnerships between Australian Indigenous and mainstream Western biomedical organisations are recognised as crucial to improved Indigenous health outcomes. However, these partnerships often experience challenges, particularly in the context of Australia’s race and political relations.

Methods

We examined the relevant literature in order to identify the potential role for social theory and theoretical models in developing and maintaining intercultural partnerships. Having identified relevant theoretical models, terms and possible key words, a range of databases were searched and relevant articles selected for inclusion. An integrative approach brought together theoretical models and practical considerations about working in partnership, to inform our analysis of the literature.

Findings

Considering partnerships between Australian Indigenous and mainstream health organisations as ‘bi-cultural’ is simplistic: rather they are culturally diverse across social and professional levels. As such, partnerships between Australian Indigenous and mainstream health organisations may be better conceptualised as ‘intercultural’, operating across diverse and shifting cultural frames of reference. Theories identified by this review as useful to guide partnerships include power relations, reflexivity and dialogue, borders and strangeness and the intercultural or third space. This paper examines how these theoretical approaches can develop understanding and improve intercultural engagement between mainstream and Australian Indigenous partners in healthcare.

Conclusions

Rather than viewing partnerships merely as arrangements between disembodied entities, sometimes contractual in nature, they are better seen as activities between people and organisations and essentially dependent on relationships, occurring in an intercultural space that is complex, dynamic and subject to changes in power relations. Theoretical models aiming to understand and improve partnerships indicate the complexity of building and maintaining such partnerships and stress the importance of understanding factors that can strengthen or derail their effectiveness. While the theories presented here are by no means exhaustive, they nonetheless provide a series of entry points through which to engage with the issue and expand the discourse. This approach allows the transformative nature of Australian Indigenous-mainstream ‘culture’ to be explored and understood in its lived expression; rather than relegated to prescriptive categories.

Aboriginal-mainstream partnerships: exploring the challenges and enhancers of a collaborative service arrangement for Aboriginal clients with substance use issues

BACKGROUND

Partnerships between different health services are integral to addressing the complex health needs of vulnerable populations. In Australia, partnerships between Aboriginal community controlled and mainstream services can extend health care options and improve the cultural safety of services. However, although government funding supports such collaborations, many factors can cause these arrangements to be tenuous, impacting the quality of health care received. Research was undertaken to explore the challenges and enhancers of a government initiated service partnership between an Aboriginal Community Controlled alcohol and drug service and three mainstream alcohol rehabilitation and support services.

METHODS

Sixteen staff including senior managers (n=5), clinical team leaders (n=5) and counsellors (n=6) from the four services were purposively recruited and interviewed. Interviews were semi-structured and explored staff experience of the partnership including the client intake and referral process, shared client care, inter-service communication and ways of working.

RESULTS & DISCUSSION

Communication issues, partner unfamiliarity, 'mainstreaming' of Aboriginal funding, divergent views regarding staff competencies, client referral issues, staff turnover and different ways of working emerged as issues, emphasizing the challenges of working with a population with complex issues in a persistent climate of limited resourcing. Factors enhancing the partnership included adding a richness and diversity to treatment possibilities and opportunities to explore different, more culturally appropriate ways of working.

CONCLUSION

While the literature strongly advises partnerships be suitably mature before commencing service delivery, the reality of funding cycles may require partnerships become operational before relationships are adequately consolidated. Allowing sufficient time and funding for both the operation and relational aspects of a partnership is critical, with support for partners to regularly meet and workshop arrangements. Documentation that makes clear and embeds working arrangements between partners is important to ameliorate many of the issues that can arise. Given the historical undercurrents, flexible approaches are required to focus on strengths that contribute to progress, even if incremental, rather than on weaknesses which can undermine efforts. This research offers important lessons to assist other services collaborating in post-colonial settings to offer treatment pathways for vulnerable populations.

Acceptability of participatory social network analysis for problem-solving in Australian Aboriginal health service partnerships

BACKGROUND

While participatory social network analysis can help health service partnerships to solve problems, little is known about its acceptability in cross-cultural settings. We conducted two case studies of chronic illness service partnerships in 2007 and 2008 to determine whether participatory research incorporating social network analysis is acceptable for problem-solving in Australian Aboriginal health service delivery.

METHODS

Local research groups comprising 13-19 partnership staff, policy officers and community members were established at each of two sites to guide the research and to reflect and act on the findings. Network and work practice surveys were conducted with 42 staff, and the results were fed back to the research groups. At the end of the project, 19 informants at the two sites were interviewed, and the researchers conducted critical reflection. The effectiveness and acceptability of the participatory social network method were determined quantitatively and qualitatively.

RESULTS

Participants in both local research groups considered that the network survey had accurately described the links between workers related to the exchange of clinical and cultural information, team care relationships, involvement in service management and planning and involvement in policy development. This revealed the function of the teams and the roles of workers in each partnership. Aboriginal workers had a high number of direct links in the exchange of cultural information, illustrating their role as the cultural resource, whereas they had fewer direct links with other network members on clinical information exchange and team care. The problem of their current and future roles was discussed inside and outside the local research groups. According to the interview informants the participatory network analysis had opened the way for problem-solving by "putting issues on the table". While there were confronting and ethically challenging aspects, these informants considered that with flexibility of data collection to account for the preferences of Aboriginal members, then the method was appropriate in cross-cultural contexts for the difficult discussions that are needed to improve partnerships.

CONCLUSION

Critical reflection showed that the preconditions for difficult discussions are, first, that partners have the capacity to engage in such discussions, second, that partners assess whether the effort required for these discussions is balanced by the benefits they gain from the partnership, and, third, that "boundary spanning" staff can facilitate commitment to partnership goals.

Community capacity building in practice: constructing its meaning and relevance to health promoters

Community capacity building (CCB) is held up as a benchmark for sustainable health promotion, reflecting the empowering discourse of the Ottawa Charter (WHO 1986). In light of concerns that this language may be that of the presiding bureaucratic elite rather than the realities of those working directly with communities (Laverack & Labonte 2000), we question whether CCB reflects the work of New Zealand health promoters. The aim of this study is to assess what CCB means to health promoters and how relevant it is to their work in New Zealand. Focus groups and interviews were carried out with 64 health promoters between January 2008 and March 2009. The results of this qualitative study indicated that, while the terminology of CCB is poorly established in New Zealand, the overwhelming majority of participants felt that, to be an effective health promoter, they needed the buy-in and support of the communities in which they work. As a result, community-driven approaches have emerged as a core component of good health promotion practice in New Zealand. Yet, the concept of CCB was applied loosely with health promoters adopting language and practices corresponding more with the nuances of community development. The limited use of systematic approaches to building community capacity was accompanied by few successes achieving sustainable health promotion programmes. In prioritising community relationships many health promoters were placed in an ideological bind whereby achieving community ownership over health promotion meant compromising the evidence base of their programmes. Academic discussions of CCB appear to have gained little traction into the realm of health promotion practice in New Zealand highlighting the need for relevant research with a strong grounding in practice.

Integrating an ecological approach into an Aboriginal community-based chronic disease prevention program: a longitudinal process evaluation

Background

Public health promotes an ecological approach to chronic disease prevention, however, little research has been conducted to assess the integration of an ecological approach in community-based prevention programs. This study sought to contribute to the evidence base by assessing the extent to which an ecological approach was integrated into an Aboriginal community-based cardiovascular disease (CVD) and type 2 diabetes prevention program, across three-intervention years.

Methods

Activity implementation forms were completed by interview with implementers and participant observation across three intervention years. A standardised ecological coding procedure was applied to assess participant recruitment settings, intervention targets, intervention strategy types, extent of ecologicalness and organisational partnering. Inter-rater reliability for two coders was assessed at Kappa = 0.76 (p < .0.001), 95% CI (0.58, 0.94).

Results

215 activities were implemented across three intervention years by the health program (HP) with some activities implemented in multiple years. Participants were recruited most frequently through organisational settings in years 1 and 2, and organisational and community settings in year 3. The most commonly utilised intervention targets were the individual (IND) as a direct target, and interpersonal (INT) and organisational (ORG) environments as indirect targets; policy (POL), and community (COM) were targeted least. Direct (HP→ IND) and indirect intervention strategies (i.e., HP→ INT→ IND, HP→ POL → IND) were used most often; networking strategies, which link at least two targets (i.e., HP→[ORG-ORG]→IND), were used the least. The program did not become more ecological over time.

Conclusions

The quantity of activities with IND, INT and ORG targets and the proportion of participants recruited through informal cultural networking demonstrate community commitment to prevention. Integration of an ecological approach would have been facilitated by greater inter-organisational collaboration and centralised planning. The upfront time required for community stakeholders to develop their capacity to mobilise around chronic disease is at odds with short-term funding cycles that emphasise organisational accountability.

Community wide interventions for increasing physical activity

BACKGROUND

Multi-strategic community wide interventions for physical activity are increasingly popular but their ability to achieve population level improvements is unknown.

OBJECTIVES

To evaluate the effects of community wide, multi-strategic interventions upon population levels of physical activity.

SEARCH STRATEGY

We searched the Cochrane Public Health Group Specialised Register, The Cochrane Library, MEDLINE, MEDLINE in Process, EMBASE, CINAHL, LILACS, PsycINFO, ASSIA, The British Nursing Index, Chinese CNKI databases, EPPI Centre (DoPHER, TRoPHI), ERIC, HMIC, Sociological Abstracts, SPORTDiscus, Transport Database and Web of Science (Science Citation Index, Social Sciences Citation Index, Conference Proceedings Citation Index). We also scanned websites of the EU Platform on Diet, Physical Activity and Health; Health-Evidence.ca; the International Union for Health Promotion and Education; the NIHR Coordinating Centre for Health Technology (NCCHTA) and NICE and SIGN guidelines. Reference lists of all relevant systematic reviews, guidelines and primary studies were followed up. We contacted experts in the field from the National Obesity Observatory Oxford, Oxford University; Queensland Health, Queensland University of Technology, the University of Central Queensland; the University of Tennessee and Washington University; and handsearched six relevant journals. The searches were last updated to the end of November 2009 and were not restricted by language or publication status.

SELECTION CRITERIA

Cluster randomised controlled trials, randomised controlled trials (RCT), quasi-experimental designs which used a control population for comparison, interrupted time-series (ITS) studies, and prospective controlled cohort studies (PCCS) were included. Only studies with a minimum six-month follow up from the start of the intervention to measurement of outcomes were included. Community wide interventions had to comprise at least two broad strategies aimed at physical activity for the whole population. Studies which randomised individuals from the same community were excluded.

DATA COLLECTION AND ANALYSIS

At least two review authors independently extracted the data and assessed the risk of bias of each included study. Non-English language papers were reviewed with the assistance of an epidemiologist interpreter. Each study was assessed for the setting, the number of included components and their intensity. Outcome measures were grouped according to whether they were dichotomous (physically active, physically active during leisure time and sedentary or physically inactive) or continuous (leisure time physical activity, walking, energy expenditure). For dichotomous measures we calculated the unadjusted and adjusted risk difference, and the unadjusted and adjusted relative risk. For continuous measures we calculated net percentage change from baseline, unadjusted and adjusted risk difference, and the unadjusted and adjusted relative risk.

MAIN RESULTS

After the selection process had been completed 25 studies were included in the review. Of the included studies, 19 were set in high income countries, using the World Bank economic classification, and the remaining six were in low income countries. The interventions varied by the number of strategies included and their intensity. Almost all of the interventions included a component of building partnerships with local governments or non-governmental organisations (NGOs) (22 studies). None of the studies provided results by socio-economic disadvantage or other markers of equity consideration. However of those included studies undertaken in high income countries, 11 studies were described by the authors as being provided to deprived, disadvantaged, or low socio-economic communities.Fifteen studies were identified as having a high risk of bias, 10 studies were unclear, and no studies had a low risk of bias. Selection bias was a major concern with these studies, with only one study using randomisation to allocate communities (Simon 2008). No studies were judged as being at low risk of selection bias although 16 studies were considered to have an unclear risk of bias. Eleven studies had a high risk of detection bias, 10 with an unclear risk and four with no risk. Assessment of detection bias included an assessment of the validity of the measurement tools and quality of outcome measures. The effects reported were inconsistent across the studies and the measures. Some of the better designed studies showed no improvement in measures of physical activity. Publication bias was evident.

AUTHORS' CONCLUSIONS

Although numerous studies have been undertaken, there is a noticeable inconsistency of the findings of the available studies and this is confounded by serious methodological issues within the included studies. The body of evidence in this review does not support the hypothesis that multi-component community wide interventions effectively increase population levels of physical activity. There is a clear need for well-designed intervention studies and such studies should focus on the quality of the measurement of physical activity, the frequency of measurement and the allocation to intervention and control communities.

Closing the (service) gap: exploring partnerships between Aboriginal and mainstream health services

Background. Although effective partnerships between Aboriginal and mainstream health services are critical to improve Aboriginal health outcomes, many factors can cause these partnerships to be tenuous and unproductive. Understanding the elements of best practice for successful partnerships is essential. Methods. A literature review was conducted in 2009 using keyword searches of electronic databases. Sourced literature was assessed for relevance regarding the benefits, challenges, lessons learnt and factors contributing to successful Aboriginal and mainstream partnerships. Key themes were collated. Results. Although there is much literature regarding general partnerships generally, few specifically examine Aboriginal and mainstream health service partnerships. Twenty-four sources were reviewed in detail. Benefits include broadening service capacity and improving the cultural security of healthcare. Challenges include the legacy of Australia’s colonial history, different approaches to servicing clients and resource limitations. Recommendations for success include workshopping tensions early, building trust and leadership. Conclusion. Although successful partnerships are crucial to optimise Aboriginal health outcomes, failed collaborations risk inflaming sensitive Aboriginal–non-Aboriginal relationships. Factors supporting successful partnerships remind us to develop genuine, trusting relationships that are tangibly linked to the Aboriginal community. Failure to invest in this relational process and push forward with ‘business as usual’ can ultimately have negative ramifications on client outcomes. What is known about the topic? Partnerships between different health services have long been recognised as beneficial for broadening service capacity and using resources more effectively to improve client care. The current policy climate particularly recognises partnerships between Aboriginal and mainstream services as offering multiple benefits for improving the cultural and clinical capacity of health service delivery to Aboriginal clients. Yet many challenges face these arrangements, including tensions stemming from historical and current race relations, different ways of working and ongoing Aboriginal disadvantage. What does this paper add? Although partnerships between Aboriginal and mainstream services are strongly advocated for, there is a paucity of research on the challenges in these arrangements and practical suggestions on how to make such partnerships genuinely successful. This paper analyses the results from research, case studies, reports and reviews to identify the factors that challenge and enhance partnerships between Aboriginal and mainstream health services. The collation of this information also enables indicators of best practice to be presented. What are the implications for practitioners? Although there are considerable challenges for Aboriginal and mainstream health services entering into partnerships, this paper offers health service practitioners and managers a summary of lessons learnt and a ‘checklist’ of best practice indicators to assist them in developing, implementing and sustaining a successful collaborative arrangement.

The New Zealand experience in peer support interventions among people with diabetes

BACKGROUND

Peer-to-peer support has the potential to assist people with diabetes, or at risk of diabetes.

OBJECTIVE

To review the development of diabetes peer support initiatives in New Zealand.

METHODS

A systematic review of diabetes peer support publications from New Zealand, supplemented by unpublished records from Diabetes New Zealand (DNZ, the national diabetes patient organization) and the two major regional initiatives in South Auckland and Waikato.

RESULTS

DNZ, which has 40 societies and 71 diabetes support groups, delivers a range of services to members and non-members. The membership is mainly older European New Zealanders with diabetes, with some Maori and associated societies for Pacific and Youth. While demand exists, no quantitative evaluation of health impact by these organizations has been undertaken. Other peer support groups have developed in South Auckland and Northland. Common themes that emerge relate to leadership, organization and balancing the different needs of people with diabetes at different stages (e.g. newly diagnosed versus others) and with different personal needs. In South Auckland and the Waikato, lay educators have been trained to provide 1:1 and group sessions for people with, or at high risk of, diabetes. A range of training, management, funding and organizational barriers existed in the implementation of these lay educator programmes. Conclusions. Peer-to-peer support and education programmes in diabetes have been considered useful in New Zealand. Knowledge regarding training, management and organization is nearing a level, which would allow formal evaluation of a strategy for both the prevention of diabetes and in supporting people with diabetes.

Reflections on a community and university research collaboration

OBJECTIVE

This paper reflects on the collaborative research relationship between university and community researchers. It identifies emergent themes expressed in the words of researchers and recommends strategies to assist with other research collaborations.

CONCLUSIONS

Emergent themes included: Initial reticence by community members followed by positive experiences; the value of empowerment frameworks in research; building trust between community and university researchers; capacity building, management, and workloads; and community politics, misunderstandings and wealth disparity. The paper recommends strategies for successful research collaborations and identifies challenges to research collaborations.

The research dance: university and community research collaborations at Yarrabah, North Queensland, Australia

This article reflects upon collaborative research relationships between indigenous communities and universities in social health and empowerment programmes. This article is focused on Family Well Being programme and Indigenous Men's Support Groups conducted over the last decade at Yarrabah in northern Queensland. These programmes have incorporated a process whereby the community has set research agendas, local researchers have been employed, and university researchers have facilitated the development of appropriate programmes, the capacity of the community to manage these, and programme evaluation. This article draws upon reflective data derived from intensive group workshops and semistructured, in-depth interviews with both community and university-based researchers conducted in late 2006 and early 2007. These workshops and interviews describe, often in the words of participants, the experiences, challenges and strategies for research collaborations. This article recommends positive strategies for successful partnerships and outlines some challenges faced by both community and university researchers in programmes. The findings of the interviews and workshops are thematically discussed in relation to international literature on collaborative research.

Development and piloting of a community health worker-based intervention for the prevention of diabetes among New Zealand Maori in Te Wai o Rona: Diabetes Prevention Strategy

OBJECTIVE

The progression from impaired glucose tolerance (IGT)/impaired fasting glucose (IFG) to type 2 diabetes can be prevented or delayed through intensive lifestyle changes. How to translate this to implementation across whole communities remains unclear. We now describe the results to a pilot of a personal trainer (Maori Community Health Worker, MCHW) approach among Maori in New Zealand.

DESIGN, SETTING AND SUBJECTS

A randomised cluster-controlled trial of intensive lifestyle change was commenced among 5,240 non-pregnant Maori family members without diabetes from 106 rural and 106 urban geographical clusters. Baseline assessments included lifestyle questionnaires, anthropometric measurements and venesection. A pilot study (Vanguard Study) cohort of 160 participants were weighed before and during MCHW intervention, and compared with fifty-two participants weighed immediately before intervention and with 1,143 participants from the same geographical area. Interactions between participants and the MCHW were reported using personal digital assistants with a programmed detailed structured approach to each interview.

RESULTS

During the Vanguard Study, participants and MCHW found the messages, toolkit and delivery approach acceptable. Those with IGT/IFG diagnosed (n 27) experienced significant weight loss after screening and during the Vanguard Study (5.2 (sd 6.6) kg, paired t test P < 0.01). Significant weight loss occurred during the Vanguard Study among all participants (-1.3 (sd 3.6) kg, P < 0.001).

CONCLUSIONS

Comparable initial weight loss was shown among those with IGT/IFG and those from existing trials. Community-wide prevention programmes are feasible among Maori and are likely to result in significant reductions in the incidence of diabetes.

Beyond policy and planning to practice: getting sexual health on the agenda in Aboriginal communities in Western Australia

Background

Indigenous Australians have significantly poorer status on a large range of health, educational and socioeconomic measures and successive Australian governments at state and federal level have committed to redressing these disparities. Despite this, improvements in Aboriginal health status have been modest, and Australia has much greater disparities in the health of its Indigenous people compared to countries that share a history characterised by colonisation and the dispossession of indigenous populations such as New Zealand, Canada and the United States of America. Efforts at policy and planning must ultimately be translated into practical strategies. This article outlines an approach that was effective in Western Australia in increasing the engagement and concern of Aboriginal people about high rates of sexually transmissible infections and sexual health issues. Many aspects of the approach are relevant for other health issues.

Results

The complexity of Indigenous sexual health necessitates inter-agency and cross-governmental collaboration, in addition to Aboriginal leadership, accurate data, and community support. A recent approach covering all these areas is described. This has resulted in Aboriginal sexual health being more actively discussed within Aboriginal health settings than it once was and additional resources for Indigenous sexual health being available, with better communication and partnership across different health service providers and sectors. The valuable lessons in capacity building, collaboration and community engagement are readily transferable to other health issues, and may be useful for other health professionals working in the challenging area of Aboriginal health.

Conclusion

Health service planners and providers grapple with achieving Aboriginal ownership and leadership regarding their particular health issue, despite sincere concern and commitment to addressing Aboriginal health issues. This highlights the need to secure genuine Aboriginal engagement. Building capacity that enables Indigenous people and communities to fulfill their own goals is a long-term strategy and requires sustained commitment, but we argue is a prerequisite for better Indigenous health outcomes.

Applying comprehensive community-based approaches in diabetes prevention: rationale, principles, and models

The literature regarding the prevention of diabetes provides few standards for community-based initiatives. The present article offers four principles for engaging communities in comprehensive community approaches to diabetes prevention including (1) facilitating meaningful and central roles for communities, (2) giving primary attention to participatory processes rather than to best practices, (3) emphasizing cultural relevance in designing interventions particularly in racial and ethnic communities, and (4) incorporating social ecology approaches that are holistic and that address larger environmental influences rather than individual behavioral change alone. In order that community public health practitioners may operationalize the principles, models are provided for each.

Attendance for general practitioner asthma care by children with moderate to severe asthma in Auckland, New Zealand

Attendance for general practitioner (GP) care of childhood asthma varies widely in New Zealand (NZ). There is little current research to account for the variations, although groups such as Māori and Pacific peoples have traditionally faced barriers to accessing GP care. This paper aims to describe and account for attendance levels for GP asthma care among 6-9 year-olds with moderate to severe asthma in Auckland, NZ. During 2002, randomly selected schools identified all 6-9 year-olds with possible breathing problems. Completion of a questionnaire by each parent/guardian indicated which children had moderate to severe asthma, and what characteristics influenced their access to GP asthma care. A multilevel, negative binomial regression model (NBRM) was fitted to account for the number of reported GP visits for asthma, with adjustment for clustering within schools. Twenty-six schools (89.7 percent) identified 931 children with possible breathing problems. Useable questionnaires were returned to schools by 455 children (48.9 percent). Results indicated 209 children with moderate to severe asthma, almost one in every three reportedly making 5 or more GP visits for asthma in the previous year. Māori, Pacific and Asian children were disproportionately represented among these 'high attendees'. Low attendees (0-2 visits) were mainly NZ Europeans. The NBRM (n=155) showed that expected visits were increased by perceived need, ill-health, asthma severity and, in particular, Māori and Pacific child ethnicity. It may be that Māori and Pacific children no longer face significant barriers to accessing GP asthma care. However, more likely is that barriers apply only to accessing routine, preventative care, leading to poor asthma control, exacerbations requiring acute care, and paradoxically an increase in GP visits. That barriers may increase total numbers of visits challenges the assumption, for all health systems, that access can be defined in terms of barriers that must be overcome to obtain health care.

Tale of two churches: differential impact of a church-based diabetes control programme among Pacific Islands people in New Zealand

AIMS

To compare the impact on weight and exercise of a 2-year church-based diabetes risk reduction programme in four churches in South Auckland, New Zealand.

METHODS

A prospective non-randomized controlled study of a modular lifestyle and diabetes awareness intervention programme applying community development principles. The study involved four complete church congregations, two Samoan and two Tongan, with 516 participants at commencement. Risk of Type 2 diabetes is high among both ethnic groups.

RESULTS

Overall, 285 subjects were available for their second assessment. In one intervention church, weight gain was controlled (vs. control 0 +/- 4.8 vs. +3.1 +/- 9.8 kg, respectively; P=0.05), diabetes knowledge (+46 +/- 26% vs. +4 +/- 17%; P<0.001) and regular exercise (at least 3 days per week: +22% vs. -8%; P=0.032) increased and readiness to change weight (P=0.007) shifted towards maintenance (e.g. maintenance +41% vs. +8%, respectively). The other intervention church increased diabetes knowledge (+19 +/- 24 vs. +8 +/- 25; P<0.024), but no other significant personal changes occurred. Attendance and perceived utility of the programme were greater in the first intervention church.

CONCLUSIONS

A moderate intensity, community-based, structured diabetes awareness and lifestyle programme can reduce diabetes risk, but increasing diabetes knowledge alone is not necessarily associated with healthier lifestyle choices. Continuous and detailed monitoring of penetration of interventions may be essential to help guide the timing of interventions and identify the need for additional strategies to increase participation and motivation.

Community governance of the Kahnawake Schools Diabetes Prevention Project, Kahnawake Territory, Mohawk Nation, Canada

Health promotion emphasizes the importance of community ownership in the governance of community-based programmes, yet little research has been conducted in this area. This study examined perceptions of community ownership among project partners taking responsibility for decision-making related to the Kahnawake Schools Diabetes Prevention Project (KSDPP). Project partners were surveyed cross-sectionally at 18 months (T1) and 60 months (T2) into the project. The perceived influence of each project partner was assessed at T1 and T2 for three domains: (i) KSDPP activities; (ii) KSDPP operations; and (iii) Community Advisory Board (CAB) activities. Project staff were perceived to have the greatest influence on KSDPP activities, KSDPP operations and CAB activities at both T1 and T2. High mean scores of perceived influence for CAB members and community researchers, however, suggests that project decision-making was a shared responsibility among multiple community partners. Although academic researcher influence was consistently low, they were satisfied with their level of influence. This was unlike community affiliates, who were less satisfied with their lower level of influence. In keeping with Kanien'kehaka (Mohawk) culture, the findings suggest a participatory democracy or shared decision-making as the primary mode of governance of KSDPP.

Development of guidelines for non-indigenous people undertaking research among the indigenous population of north-east Victoria

The Department of Rural Health, University of Melbourne, has developed a framework for conducting research in partnership with Indigenous communities. The framework addresses past inappropriate research practices, incorporates cultural understandings, and outlines culturally appropriate protocols. The four parts of the framework are a committee to initiate, direct and oversee all research projects; a Koorie Team to guide research; a set of research guidelines; and a policy for the department. The framework has been used to develop strong relations with Koorie communities and conduct various health projects.

Researching Aboriginal health: experience from a study of urban young people's health and well-being

European colonisation had a devastating effect on the health and well-being of indigenous people in Australia. The history of Aboriginal health research has reflected the history of colonisation; research has understandably been viewed with distrust. The need for accurate statistics and improved understanding of health problems is clear, but obtaining them is not easy. In this paper we describe the first stage of a study of the health and well-being of urban young people that was initiated and carried out by the Victorian Aboriginal Health Service (VAHS), a community controlled organisation. This longitudinal study aims to describe the prevalence and incidence of a range of health problems, to explore their interrelated determinants, and to increase the capacity of the VAHS to carry out research. The process of planning and carrying out this study raised a number of interesting ethical, cultural and methodological issues. These issues include the establishment of an appropriate and properly constituted local ethics committee, the difficulty of obtaining a representative sample, the need for ongoing negotiation, attention to language, the use of a subject-generated identity code, and the need to recruit a wide range of peer interviewers. Achievements include a series of community reports of the findings, the establishment of a cohort of young people for a longitudinal study; a shift in attitudes toward research; a strengthened network of young Kooris; increased use of the health service by young people and the establishment of an after-hours clinic service and meeting place for young people. The aim of this analysis of our achievements and constraints is to assist others planning similar research, and to demonstrate the value for process and outcomes of research conducted under Aboriginal community control.