Critical reflection for researcher-community partnership effectiveness: the He Pikinga Waiora process evaluation tool guiding the implementation of chronic condition interventions in Indigenous communities

Facilitators and barriers for implementation of health programmes with Māori communities

BACKGROUND

Addressing health inequities that Māori (Indigenous peoples) communities face in New Zealand is a key aim of researchers and practitioners. However, there is limited understanding of the implementation processes and outcomes of health programmes for addressing these inequities. The aim of this study was twofold: (a) to identify correlates of implementation outcomes and (b) to identify facilitators and barriers to implementation effectiveness.

METHODS

The study involved a concurrent mixed method approach. Through an online survey, 79 participants with experience in implementing a health programme with a Māori community identified outcomes and processes of the programme. Additionally, nine Māori community providers shared their perceptions and experience of facilitators and barriers to implementation effectiveness through an in-depth interview. The quantitative and qualitative findings were integrated to address the aims of the study.

RESULTS

For the first aim, we identified two key outcomes: overall health impacts and sustainability. Three of the variables had significant and positive bivariate correlations with health impacts: cultural alignment, community engagement, and individual skills. The only significant correlate of sustainability was evidence-based. For the second aim, participants described four facilitators (leadership, whanaungatanga [relationships], sharing information, digestible information) and four barriers (system constraints, lack of funding, cultural constraints, lack of engagement) to effective implementation.

CONCLUSION

Overall, leadership, aligning culture, and building on whanaungatanga, while getting financial resources and systems support, are the core elements to supporting implementation efforts in Māori communities.

Adapting an equity-focused implementation process framework with a focus on ethnic health inequities in the Aotearoa New Zealand context

BACKGROUND

Health intervention implementation in Aotearoa New Zealand (NZ), as in many countries globally, usually varies by ethnicity. Māori (the Indigenous peoples of Aotearoa) and Pacific peoples are less likely to receive interventions than other ethnic groups, despite experiencing persistent health inequities. This study aimed to develop an equity-focused implementation framework, appropriate for the Aotearoa NZ context, to support the planning and delivery of equitable implementation pathways for health interventions, with the intention of achieving equitable outcomes for Māori, as well as people originating from the Pacific Islands.

METHODS

A scoping review of the literature to identify existing equity-focused implementation theories, models and frameworks was undertaken. One of these, the Equity-based framework for Implementation Research (EquIR), was selected for adaptation. The adaptation process was undertaken in collaboration with the project's Māori and consumer advisory groups and informed by the expertise of local health equity researchers and stakeholders, as well as the international implementation science literature.

RESULTS

The adapted framework's foundation is the principles of Te Tiriti o Waitangi (the written agreement between Māori rangatira (chiefs) and the British Crown), and its focus is whānau (extended family)-centred implementation that meets the health and wellbeing aspirations, priorities and needs of whānau. The implementation pathway comprises four main steps: implementation planning, pathway design, monitoring, and outcomes and evaluation, all with an equity focus. The pathway is underpinned by the core constructs of equitable implementation in Aotearoa NZ: collaborative design, anti-racism, Māori and priority population expertise, cultural safety and values-based. Additionally, the contextual factors impacting implementation, i.e. the social, economic, commercial and political determinants of health, are included.

CONCLUSIONS

The framework presented in this study is the first equity-focused process-type implementation framework to be adapted for the Aotearoa NZ context. This framework is intended to support and facilitate equity-focused implementation research and health intervention implementation by mainstream health services.

A scoping review of equity-focused implementation theories, models and frameworks in healthcare and their application in addressing ethnicity-related health inequities

BACKGROUND

Inequities in implementation contribute to the unequal benefit of health interventions between groups of people with differing levels of advantage in society. Implementation science theories, models and frameworks (TMFs) provide a theoretical basis for understanding the multi-level factors that influence implementation outcomes and are used to guide implementation processes. This study aimed to identify and analyse TMFs that have an equity focus or have been used to implement interventions in populations who experience ethnicity or 'race'-related health inequities.

METHODS

A scoping review was conducted to identify the relevant literature published from January 2011 to April 2022 by searching electronic databases (MEDLINE and CINAHL), the Dissemination and Implementation model database, hand-searching key journals and searching the reference lists and citations of studies that met the inclusion criteria. Titles, abstracts and full-text articles were screened independently by at least two researchers. Data were extracted from studies meeting the inclusion criteria, including the study characteristics, TMF description and operationalisation. TMFs were categorised as determinant frameworks, classic theories, implementation theories, process models and evaluation frameworks according to their overarching aim and described with respect to how equity and system-level factors influencing implementation were incorporated.

RESULTS

Database searches yielded 610 results, 70 of which were eligible for full-text review, and 18 met the inclusion criteria. A further eight publications were identified from additional sources. In total, 26 papers describing 15 TMFs and their operationalisation were included. Categorisation resulted in four determinant frameworks, one implementation theory, six process models and three evaluation frameworks. One framework included elements of determinant, process and evaluation TMFs and was therefore classified as a 'hybrid' framework. TMFs varied in their equity and systems focus. Twelve TMFs had an equity focus and three were established TMFs applied in an equity context. All TMFs at least partially considered systems-level factors, with five fully considering macro-, meso- and micro-level influences on equity and implementation.

CONCLUSIONS

This scoping review identifies and summarises the implementation science TMFs available to support equity-focused implementation. This review may be used as a resource to guide TMF selection and illustrate how TMFs have been utilised in equity-focused implementation activities.

Adaptation and implementation processes of a culture-centred community-based peer-education programme for older Māori

Background

Health inequities experienced by kaumātua (older Māori) in Aotearoa, New Zealand, are well documented. Examples of translating and adapting research into practice that identifies ways to help address such inequities are less evident. The study used the He Pikinga Waiora (HPW) implementation framework and the Consolidated Framework for Implementation Research (CFIR) to explore promising co-design and implementation practices in translating an evidence-based peer-education programme for older Māori to new communities.

Methods

The study was grounded in an Indigenous methodology (Kaupapa Māori) and a participatory research approach. Data were collected from research documentation, community meeting and briefing notes, and interviews with community researchers.

Results

The data analysis resulted in several key promising practices: Kaumātua mana motuhake (kaumātua independence and autonomy) where community researchers centred the needs of kaumātua in co-designing the programme with researchers; Whanaungatanga (relationships and connectedness) which illustrated how community researchers’ existing and emerging relationships with kaumātua, research partners, and each other facilitated the implementation process; and Whakaoti Rapanga (problem-solving) which centred on the joint problem-solving undertaken by the community and university researchers, particularly around safety issues. These results illustrate content, process, and relationship issues associated with implementation effectiveness.

Conclusions

This study showed that relational factors are central to the co-design process and also offers an example of a braided river, or He Awa Whiria, approach to implementation. The study offers a valuable case study in how to translate, adapt, and implement a research-based health programme to Indigenous community settings through co-design processes.

Trial registration

The project was registered on 6 March 2020 with the Australia New Zealand Clinical Trial Registry: ACTRN12620000316909. Prospectively registered.

Healthier Lives Implementation Research Network for Māori and Pacific community health providers in Aotearoa New Zealand: a study protocol with an observational mixed methods design

BACKGROUND

Despite incremental gains in the Aotearoa New Zealand health sector, Māori and Pacific peoples still experience poorer health outcomes than non-Māori and non-Pacific. Access to the latest research and innovation is critical to improving and addressing health outcomes and health inequities in particular. However, there are numerous challenges to translating research into practice including that there is currently no known a specific infrastructure in Aotearoa New Zealand to facilitate this process. The aim of the project is to develop a network of community providers, researchers and health systems representatives that can help facilitate the implementation of novel and innovative programmes and products that help to meet the health needs of Māori and Pacific communities.

METHODS

This project has three stages, one of which has been completed. In Stage 1, we engaged with key leaders of organisations from various components in the health system through a co-design process to identify parameters and infrastructure of the network. In Stage 2, we propose to construct the network involving approximately 20-30 community providers (and other affiliated researchers and health system representatives) and refine its parameters through an additional co-design process. Additionally, we will use a mixed methods research design using survey and interviews to identify perceived implementation needs, facilitators and barriers to help inform the work in the third stage. In Stage 3, we will support the active implementation of evidence-based programmes with a smaller number of providers (approximately four to eight community providers depending on the complexity of the implementation). Mixed methods research will be conducted to understand facilitators and barriers to implementation processes and outcomes.

DISCUSSION

The proposed network infrastructure is an equity-oriented strategy focused on building capacity through a strength-based approach that can help address inequities over time. Our "proof-of-concept" study will not be able to change inequities in that time period given its relatively small scale and time period, but it should set the foundation for continued equity-oriented work.

Navigating the space between co-design and mahitahi: Building bridges between knowledge systems on behalf of communities

AIMS

To provide knowledge and recommendations for researchers, health professionals and policymakers on navigating between science and mātauranga (knowledge) Māori when using co-design methodologies.

CONTEXT

It is well known that the health system in Aotearoa/New Zealand does not provide culturally responsive services, programmes or approaches. Indigenous, remote and vulnerable populations that are not well served by medical and scientific models would be better served by the underlying premise of co-design methodology. However, co-design is a Western methodology. Mahitahi is presented here as a culturally responsive method of co-design that builds approaches by utilising the worldview of the people that the health system most needs to have impact upon. Co-design and mahitahi have synergies, and working at the interface between Western and Māori knowledge systems can provide innovative solutions that draw on the strengths of both approaches.

APPROACH

Authors will outline the benefit co-design processes have for improving health outcomes for remote and vulnerable populations. Mahitahi will be described and the synergies with co-design emphasised with important distinctions also highlighted. The use of Indigenous knowledge systems, using Māori as the case example, will be outlined.

CONCLUSION

Recommendations will be provided to guide researchers, health professionals and policy makers when planning a co-design approach with remote and vulnerable communities.

Working together in Aboriginal health: a framework to guide health professional practice

Background

Working effectively with Aboriginal and Torres Strait Islander people is important for maximising the effectiveness of a health care interaction between and Aboriginal and Torres Strait Islander patients and a health professional. This paper presents a framework to guide health professional practice in Aboriginal and Torres Strait Islander health.

Methods

This qualitative study was based in a social constructionist epistemology and was guided by a critical social research methodology. Two methods were employed: interviews with Aboriginal health workers and allied health professionals about their experiences of working together in Aboriginal health, and an auto-ethnography conducted by the researcher, a non-Aboriginal dietitian and researcher who worked closely with two Aboriginal communities while undertaking this research.

Results

Interviews were conducted with 44 allied health professionals and Aboriginal health workers in 2010. Critical Social research, which involves the deconstruction and reconstruction of data, was used to analyse data and guided the evolution of themes. Strategies that were identified as important to guide practice when working respectfully in Aboriginal health included: Aboriginal and non-Aboriginal people working with Aboriginal health workers, using appropriate processes, demonstrating commitment to building relationships, relinquishing control, having an awareness of Aboriginal history, communication, commitment, flexibility, humility, honesty, and persistence. Reciprocity and reflection/reflexivity were found to be cornerstone strategies from which many other strategies naturally followed. Strategies were grouped into three categories: approach, skills and personal attributes which led to development of the Framework.

Conclusions

The approach, skills and personal attributes of health professionals are important when working in Aboriginal health. The strategies identified in each category provide a Framework for all health professionals to use when working with Aboriginal and Torres Strait Islander people.

A case study of using the He Pikinga Waiora Implementation Framework: challenges and successes in implementing a twelve-week lifestyle intervention to reduce weight in Māori men at risk of diabetes, cardiovascular disease and obesity

Background

Māori men have stark health inequities around non-communicable diseases. This study describes the case of a partnership attempting to develop and implement a culturally centred intervention through a collaborative partnership to potentially address the inequities. In particular, the partnership followed a participatory, co-design approach using the He Pikinga Waiora (HPW) Implementation Framework; the study presents lessons learnt in addressing health inequities following this framework.

Methods

The partnership involved a university research team and a Māori community health provider. They engaged with other stakeholders and several cohorts of Māori men through a co-design process to adapt a 12-week lifestyle intervention. The co-design process was documented through meeting notes and interviews with partners. Two cohorts participated in separate single group pre-intervention/post-intervention designs with multi-method data collection. Key outcome measures included weight loss, self-reported health, physical activity, and nutrition. Post-intervention data collection included qualitative data.

Results

The co-design process resulted in a strong and engaged partnership between the university team and the provider. There were significant challenges in implementing the intervention including having two additional partner organisations dropping out of the partnership just after the initial implementation phase. However, a flexible and adaptable partnership resulted in developing two distinct lifestyle interventions run with 32 Māori men (in two different cohorts of 8 and 24). All but one in the first cohort completed the programme. The first cohort had a modest although statistically insignificant improvement in weight loss (d = 1.04) and body mass index (BMI; d = 1.08). The second cohort had a significant reduction in weight loss (d = 1.16) and BMI (d = 1.15). They also had a significant increase in health-related quality of life (d = 1.7) and self-rated health (d = 2.0).

Conclusion

The HPW Framework appears to be well suited to advance implementation science for Indigenous communities in general and Māori in particular. The framework has promise as a policy and planning tool to evaluate and design interventions for chronic disease prevention in Indigenous communities. Despite this promise, there are structural challenges in developing and implementing interventions to address health inequities.

Trial registration

Retrospectively registered, Australia New Zealand Clinical Trials Registry, ACTRN12619001783112.