Exploring the Reported Strengths and Limitations of Aboriginal and Torres Strait Islander Health Research: A Narrative Review of Intervention Studies

High quality intervention research is needed to inform evidence-based practice and policy for Aboriginal and Torres Strait Islander communities. We searched for studies published from 2008-2020 in the PubMed database. A narrative review of intervention literature was conducted, where we identified researcher reported strengths and limitations of their research practice. A total of 240 studies met inclusion criteria which were categorised as evaluations, trials, pilot interventions or implementation studies. Reported strengths included community engagement and partnerships; sample qualities; Aboriginal and Torres Strait Islander involvement in research; culturally appropriate and safe research practice; capacity building efforts; providing resources or reducing costs for services and communities; understanding local culture and context; and appropriate timelines for completion. Reported limitations included difficulties achieving the target sample size; inadequate time; insufficient funding and resources; limited capacity of health workers and services; and inadequate community involvement and communication issues. This review highlights that community consultation and leadership coupled with appropriate time and funding, enables Aboriginal and Torres Strait Islander health intervention research to be conducted. These factors can enable effective intervention research, and consequently can help improve health and wellbeing outcomes for Aboriginal and Torres Strait Islander people.

"We're on the ground, we know what needs to be done": Exploring the role of Aboriginal Health Workers in primary health care

Background

Aboriginal Health Workers (AHWs) are core providers of primary health care (PHC) for First Nations peoples in Australia. However, the national AHW workforce is aging and in short supply. There is a poor understanding of the factors contributing to this attrition from the perspectives of AHWs themselves. This study aimed to systematically explore the current functioning and sustainability of AHWs in NSW PHC by amplifying AHW voices.

Materials and methods

This study was co-designed with three Aboriginal health services in NSW. It included a literature review exploring the role of AHWs in NSW, and yarns with AHWs and their supervisors at participating services. Yarning is an Indigenous approach to knowledge generation centered upon storytelling. The yarns were guided by the USAID-developed Community Health Worker Assessment and Improvement Matrix. Yarn transcripts were analyzed using cyclical thematic analysis to identify key facilitators and challenges for AHW practice.

Results

The yarns highlighted five categories of change that are required to ensure AHW sustainability: community connection, recognition, value, support, and an inclusive health system. The yarns revealed that there are both service- and system-level factors influencing each of these categories of change.

Conclusions

The lived experiences of AHWs in NSW emphasize five key categories of change that are required to ensure workforce sustainability. It is evident that a system-wide paradigm shift to better include holistic approaches to health is necessary to truly ensure sustainability. Co-designing similar studies with ACCHOs across NSW can help inform this change.

Exploring HbA1c variation between Australian diabetes centres: The impact of centre-level and patient-level factors

Background

Increasing global diabetes incidence has profound implications for health systems and for people living with diabetes. Guidelines have established clinical targets but there may be variation in clinical outcomes including HbA1c, based on location and practice size. Investigating this variation may help identify factors amenable to systemic improvement interventions. The aims of this study were to identify centre-specific and patient-specific factors associated with variation in HbA1c levels and to determine how these associations contribute to variation in performance across diabetes centres.

Methods

This cross-sectional study analysed data for 5,872 people with type 1 (n = 1,729) or type 2 (n = 4,143) diabetes mellitus collected through the Australian National Diabetes Audit (ANDA). A linear mixed-effects model examined centre-level and patient-level factors associated with variation in HbA1c levels.

Results

Mean age was: 43±17 years (type 1), 64±13 (type 2); median disease duration: 18 years (10,29) (type 1), 12 years (6,20) (type 2); female: 52% (type 1), 45% (type 2). For people with type 1 diabetes, volume of patients was associated with increases in HbA1c (p = 0.019). For people with type 2 diabetes, type of centre was associated with reduction in HbA1c (p <0.001), but location and patient volume were not. Associated patient-level factors associated with increases in HbA1c included past hyperglycaemic emergencies (type 1 and type 2, p<0.001) and Aboriginal and Torres Strait Islander status (type 2, p<0.001). Being a non-smoker was associated with reductions in HbA1c (type 1 and type 2, p<0.001).

Conclusions

Centre-level and patient-level factors were associated with variation in HbA1c, but patient-level factors had greater impact. Interventions targeting patient-level factors conducted at a centre level including sick-day management, smoking cessation programs and culturally appropriate diabetes education for and Aboriginal and Torres Strait Islander peoples may be more important for improving glycaemic control than targeting factors related to the Centre itself.

A mixed-methods evaluation of an urban Aboriginal diabetes lifestyle program

OBJECTIVE

The objective of this study was to evaluate an Aboriginal-led diabetes lifestyle program catering to urban Aboriginal people in an Aboriginal organisation.

METHODS

Mixed-methods study that employed routinely collected physiological data and audio-recorded focus group sessions. Physiological data were analysed using a multi-level model to account for participant clustering. Qualitative data were subject to thematic analysis.

RESULTS

Participants were overwhelmingly positive about the program. They lost weight and improved their diastolic blood pressure and glycaemic control; however, it was the feelings of belonging and optimism about their ability to improve their health that they most valued. Qualitative analysis revealed three main themes. These were: 'With the Mob', 'For the Mob' and 'Program Elements. The strengths of the program lay in its indigeneity, low-cost and easy-to-prepare diet, and cultural and communication skills of the director.

CONCLUSIONS

Recommendations for improvement included educating participants on the pathophysiology of diabetes, the refinement of online elements and the introduction of face-to-face group exercise. Implications for public health: Programs of this nature should be expanded and evaluated longitudinally with multiple cohorts.

A model of culturally-informed integrated diabetes education and eye screening in indigenous primary care services and specialist diabetes clinics: Study protocol

AIMS

To improve diabetes management in Indigenous Australians using an integrated nurse-led model of diabetes education and eye screening in indigenous primary care and specialist diabetes clinics.

DESIGN

A pre-post study.

METHODS

This study will be implemented in indigenous primary care and specialist diabetes clinics in Victoria, Australia. Participants recruited to the study will be existing adult patient with diagnosed diabetes attending study sites. A nurse-credentialled diabetes educator and certified retinal imager will deliver three study components: (a) retinal photography as a diabetic retinopathy screening and patient engagement tool; (b) lifestyle and behaviour surveys, administered at baseline and at the final visit, in 12 months. Findings from the surveys and participants' retinal images will be used to guide; and (c) personalized diabetes education. The primary outcomes are participant adherence to diabetic eye screening recommendations and health service diabetic retinopathy screening coverage. Secondary outcomes are baseline DR prevalence and changes in clinical and lifestyle risk factor levels, diabetes knowledge and satisfaction with diabetes care.

DISCUSSION

Compared with non-indigenous Australians, Indigenous Australians have a high prevalence of diabetic retinopathy and blindness, low adherence to eye screening recommendations and suboptimal health literacy. Nurse-credentialled diabetes educators can be trained to incorporate retinal imaging and eye screening into their clinical practice to give image-based diabetes education to facilitate diabetic retinopathy management.

IMPACT

Credentialled nurse diabetes educators who integrate eye screening and diabetes education can facilitate timelier diabetic retinopathy screening, referral pathways and treatment of sight-threatening retinopathy. We believe that this model of integrated diabetes education and eye screening will also improve adherence to eye screening recommendations, population screening coverage, health literacy, risk factor levels and diabetes self-care.

CLINICAL TRIAL REGISTRATION

ANZCTRN1261800120435.

Co-Developed Indigenous Educational Materials for Chronic Kidney Disease: A Scoping Review

BACKGROUND

Canadian Indigenous populations experience significantly more chronic kidney disease (CKD) than the general population. Indigenous people who live in rural and remote areas may also have difficulty accessing both information and care for their CKD. Informed decision making about treatment options for advancing kidney disease may be delayed, which can result in poor health outcomes and decreased quality of life. Moreover, Indigenous people may experience marginalization within Western health care systems.

OBJECTIVE

The objective of this scoping review is to identify culturally appropriate and co-developed Indigenous educational tools that will ultimately support CKD learning and end-stage kidney treatment decision making.

DESIGN

Scoping Review.

SETTING

Databases included Embase, CINAHL, Medline (OVID), ERIC, and the Canadian Agency for Drugs and Technology Gray Matters.

STUDY PARTICIPANTS

Community-based Indigenous patients, families, health care workers, and community members.

METHODS

We systematically reviewed the literature to explore the availability of co-developed Indigenous educational tools and material for CKD treatment options. Titles, abstracts, and full texts were reviewed independently by 2 reviewers with disagreements resolved through a third. All aspects of this project, including searching the databases were done in consultation with an Indigenous Elder.

RESULTS

Only one retrieved article identified a comprehensive CKD tool co-developed by researchers, health care providers, and an Indigenous community. Three themes emerged from the scoping review that may inform characteristics of co-developed tools: cultural appropriateness; appraisal of utility and effectiveness and; content informed by co-development of traditional and Western chronic disease knowledge.

LIMITATIONS

Consistent with scoping review methodology, the methodological quality of included studies was not assessed. In addition, it was difficult to synthesize the findings from the research and gray literature.

CONCLUSION

Little is known about the co-development of Indigenous educational tools for CKD. Further in-depth understanding is required about how to best engage with Indigenous communities, specifically to co-develop contextualized CKD tools that are acceptable to Indigenous people.Trial registration: Not applicable as this review described secondary data.

Feltman: evaluating the utilisation of an Aboriginal diabetes education tool by health professionals

Diabetes contributes considerably to the health disparities in the Aboriginal population. To address the lack of Aboriginal-specific diabetes education tools, Feltman was designed for health professionals to deliver diabetes prevention and management information. This qualitative study aims to explore how this resource was used and its perceived effect on diabetes prevention and management in Victorian Aboriginal communities. Convenience sampling was used to recruit 18 participants (n=6 were Aboriginal) who had attended Feltman training between 2010 and 2016. Semi-structured interviews conducted via telephone or face-to-face were audio-recorded, transcribed and analysed via content analysis. Content analysis identified three main categories regarding Feltman: (1) utilisation in Aboriginal and mainstream health services; (2) as a comprehensive, engaging tool that supports understanding of diabetes; and (3) the barriers and challenges to Feltman's use. Overall, Feltman was regarded as a culturally appropriate diabetes education tool that is visual, tactile, engaging, supportive of health literacy and perceived to enhance Community members' understanding of diabetes prevention and management. This is the first study to provide insight into Feltman's implementation; adding to the evidence-base for Aboriginal-specific diabetes education tools.

Community Health Worker Programs to Improve Healthcare Access and Equity: Are They Only Relevant to Low- and Middle-Income Countries?

Background: Community Health Workers (CHWs) are proven to be highly effective in low- and middle-income countries with many examples of successful large-scale programs. There is growing interest in deploying CHW programs in high-income countries to address inequity in healthcare access and outcomes amongst population groups facing disadvantage. This study is the first that examines the scope and potential value of CHW programs in Australia and the challenges involved in integrating CHWs into the health system. The potential for CHWs to improve health equity is explored.

Methods: Academic and grey literature was searched to examine existing CHW roles in the Australian primary healthcare system. Semi-structured telephone interviews were conducted with a purposive sample of 11 people including policymakers, program managers and practitioners, to develop an understanding of policy and practice.

Results: Literature on CHWs in Australia is sparse, yet combined with interview data indicates CHWs conduct a broad range of roles, including education, advocacy and basic clinical services, and work with a variety of communities experiencing disadvantage. Many, and to some extent inconsistent, terms are used for CHWs, reflecting the various strategies employed by CHWs, the characteristics of the communities they serve, and the health issues they address. The role of aboriginal health workers (AHWs) is comparatively well recognised, understood and documented in Australia with evidence on their contribution to overcoming cultural barriers and improving access to health services. Ethnic health workers assist with language barriers and increase the cultural appropriateness of services. CHWs are widely seen to be well accepted and valuable, facilitating access to health services as a trusted ‘bridge’ to communities. They work best where ‘health’ is conceived to include action on social determinants and service models are less hierarchical. Short term funding models and the lack of professional qualifications and recognition are challenges CHWs encounter.

Conclusion: CHWs serve a range of functions in various contexts in Australian primary healthcare (PHC) with a common, valued purpose of facilitating access to services and information for marginalised communities. CHWs offer a promising opportunity to enhance equity of access to PHC for communities facing disadvantage, especially in the face of rising chronic disease.

Sectoral system capacity development in health promotion: evaluation of an Aboriginal nutrition program

Issue addressed The study examined effective ways to build the capacity of health organisations and professionals in the public health sector to reduce Aboriginal chronic disease risk factors. It investigated the capacity-building strategies of the Victorian Aboriginal Community Controlled Health Organisation (VACCHO) nutrition team in the facilitation of the statewide implementation of the Victorian Aboriginal Nutrition and Physical Activity Strategy 2009-2014 (VANPAS). Methods Using a qualitative design, the study analysed the VACCHO program from 2009-2014 across five domains of capacity development: workforce, resources, organisations, partnerships and leadership. Data were sourced from archival program documents and 62 semi-structured participant interviews. Results Diverse Aboriginal and non-Aboriginal professional, organisation representatives and community participants engaged in the implementation of the VANPAS. The VACCHO team used the VANPAS to solidify participant buy-in, strengthen workforce effectiveness, increase health promotion and resource appropriateness, improve organisational policy and build an evidence-base through collaborative dialogue using action-reflection principles. Conclusion A credible, high-profile Aboriginal community led and evidence-based statewide program and a commitment to dialogue through action-reflection provided a meaningful basis for both Aboriginal community and mainstream organisational engagement. Upon this foundation, the VACCHO team built a coherent sectoral system with increased capacity to enhance the nutrition of Aboriginal Victorians. So what? In an historical context of mistrust and unmet expectations, program implementation methods that build confidence amongst collaborating Aboriginal and non-Aboriginal health agencies is fundamental to building capacity to enhance Aboriginal nutrition and health.

Assessing and Validating an Educational Resource Package for Health Professionals to Improve Smoking Cessation Care in Aboriginal and Torres Strait Islander Pregnant Women

Australian Aboriginal pregnant women have a high smoking prevalence (45%). Health professionals lack adequate educational resources to manage smoking. Resources need to be tailored to ensure saliency, cultural-sensitivity and account for diversity of Indigenous populations. As part of an intervention to improve health professionals' smoking cessation care in Aboriginal pregnant women, a resource package was developed collaboratively with two Aboriginal Medical Services. The purpose of this study was to assess and validate this resource package. A multi-centred community-based participatory 4-step process (with three Aboriginal Medical Services from three Australian states), included: (1) Scientific review by an expert panel (2) 'Suitability of Materials' scoring by two Aboriginal Health Workers (3) Readability scores (4) Focus groups with health professionals. Content was analysed using six pre-determined themes (attraction, comprehension, self-efficacy, graphics and layout, cultural acceptability, and persuasion), with further inductive analysis for emerging themes. Suitability of Material scoring was adequate or superior. Average readability was grade 6.4 for patient resources (range 5.1-7.2), and 9.8 for health provider resources (range 8.5-10.6). Emergent themes included 'Getting the message right'; 'Engaging with family'; 'Needing visual aids'; and 'Requiring practicality under a tight timeframe'. Results were presented back to a Stakeholder and Consumer Aboriginal Advisory Panel and resources were adjusted accordingly. This process ensured materials used for the intervention were culturally responsive, evidence-based and useful. This novel formative evaluation protocol could be adapted for other Indigenous and culturally diverse interventions. The added value of this time-consuming and costly process is yet to be justified in research, and might impact the potential adaption by other projects.

The barriers and facilitators that indigenous health workers experience in their workplace and communities in providing self-management support: a multiple case study

Background

The inequality in health outcomes between Indigenous (Throughout the paper, the term Indigenous will be used to represent both Aboriginal Australians and Torres Strait Islander Australians.) and non-Indigenous Australians continues to be a major public health issue. Chronic conditions are responsible for the majority of the gap in life expectancy for this population. Evidence suggests that chronic condition management models focusing on self-management have led to improved health outcomes in Indigenous populations. The Flinders Closing the Gap Program (FCTGP) is a chronic condition care planning tool which aims to engage Indigenous people in self-managing their chronic conditions. Indigenous health workers (IHWs) can provide culturally appropriate self-management support; however there is paucity in current literature describing specific barriers and facilitators that they may experience when attempting to deliver this support. This study aimed to explore IHWs’ perceptions of the effectiveness and appropriateness of the FCTGP, as an evidence-based example of self-management support, and to explore the barriers and facilitators that IHWs experience in their workplace and communities in providing self-management support.

Methods

In-depth interviews were undertaken with five IHWs, drawn from five different states in Australia. Their selection was aided by key informants from the FCTGP training unit. Interviews were recorded and transcribed verbatim, and were analysed using thematic analysis.

Results

The following themes were identified. IHWs reported that the FCTGP was appropriate, flexible and acceptable in their communities. Facilitators included factors improving client and worker empowerment, and activities around sharing knowledge. Barriers included competing priorities that clients experience relating to social determinants of health, and negative experiences within mainstream health services. IHW burnout from time pressures, lack of support, and high staff turnover were also considered important barriers.

Conclusions

This study contributes an insight into the experiences of IHWs who are considered important stakeholders in implementation and sustainability of chronic condition management programs, including the FCTGP. Recommendations focus on supporting and supplementing the role of IHWs and identify the FCTGP as a facilitator in providing self-management support to a population with complex needs.

The Implementation and Evaluation of Health Promotion Services and Programs to Improve Cultural Competency: A Systematic Scoping Review

BACKGROUND

Cultural competency is a multifaceted intervention approach, which needs to be implemented at various levels of health-care systems to improve quality of care for culturally and ethnically diverse populations. One level of health care where cultural competency is required is in the provision of health promotion services and programs targeted to diverse patient groups who experience health-care and health inequalities. To inform the implementation and evaluation of health promotion programs and services to improve cultural competency, research must assess both intervention strategies and intervention outcomes.

METHODS

This scoping review was completed as part of a larger systematic literature search conducted on evaluations of cultural competence interventions in health care in Canada, the United States, Australia, and New Zealand. Seventeen peer-reviewed databases, 13 websites and clearinghouses, and 11 literature reviews were searched. Overall, 64 studies on cultural competency interventions were found, with 22 being health promotion programs and services. A process of thematic analysis was utilized to identify key intervention strategies and outcomes reported in the literature.

RESULTS

The review identified three overarching strategies utilized in health promotion services and programs to improve cultural competency: community-focused strategies, culturally focused strategies, and language-focused strategies. Studies took different approaches to delivering culturally competent health interventions, with the majority incorporating multiple strategies from each overarching category. There were various intermediate health-care and health outcomes reported across the included studies. Most commonly reported were positive reports of patient satisfaction, patient/participant service access, and program/study retention rates. The health outcome results indicate positive potential of health promotion services and programs to improve cultural competency to impact cardiovascular disease and mental health outcomes. However, due to measurement and study quality issues, it is difficult to determine the extent of the impacts.

DISCUSSION

Examined together, these intervention strategies and outcomes provide a framework that can be used by service providers and researchers in the implementation and evaluation of health promotion services and programs to improve cultural competency. While there is evidence indicating the effectiveness of such health promotion interventions in improving intermediate and health outcomes, further attention is needed to issues of measurement and study quality.