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

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.

Ethical considerations for community-based participatory research with Sami communities in North Finland

This study examines the perspectives of Sami community members and university researchers regarding the ethical considerations for engagement in Community-Based Participatory Research (CBPR) with Sami communities in northern Finland. Key informant interviews were conducted with Sami people from Finland who were exposed to or participated in research in their communities as well as with researchers who have conducted research with the Sami in Finland across diverse topics. Five themes were identified: establishing trust, research preparation, research comprehension, research ethics, and inclusion in research. The differences in participant perspectives were compared based on their community versus researcher roles. Our findings emphasize the need for (1) strategies to develop and maintain trust between Sami communities and researchers; (2) methods to bridge concepts of bias projected onto Sami communities and researchers by the others' differing world views and beliefs about research; and (3) increased education in community-engaged methods for social and natural scientists working with Sami communities. This study supports the need for the development of formalized ethical protocols for conducting community-based engaged research with and for Sami people in Finland that ensure mutually beneficial research for all involved.

Achieving the Sustainable Development Goals: A Mixed Methods Study of Health-Related Water, Sanitation, and Hygiene (WASH) for Indigenous Shawi in the Peruvian Amazon

Sustainable Development Goal 6 (SDG-6) addresses poor water quality, inadequate sanitation, and improper hygiene, all of which negatively impact health and disproportionately impact Indigenous Peoples’ health. Understanding and responding to local contexts is critical to effectively improve water, sanitation, and hygiene (WASH); however, in-depth understanding of local knowledge, practices, and perceptions are often overlooked. As such, this study described the knowledge, practices, and perceptions of WASH held by residents of two Indigenous Shawi communities in the Peruvian Amazon. Quantitative data were collected via a cross-sectional survey and analyzed using descriptive statistics. Qualitative data were collected via interviews, PhotoVoice, focus group discussions, and participatory transect walks, and analyzed using a constant comparative approach to thematic analysis. Emergent themes included characterizing water sources, collection methods, and consumption patterns; knowledge, perceptions, and practices related to WASH; and knowledge and perceptions of health issues related to WASH. This study provides insight into the ongoing challenges related to WASH in Indigenous communities in the Peruvian Amazon and highlights the need to prioritize interventions that will advance WASH-related SDGs.

Role of non-Indigenous researchers in Indigenous health research in Australia: a review of the literature

Objective This paper explores the body of knowledge around Indigenous health research and aims to outline what roles are appropriate for non-Indigenous researchers within Indigenous health research in Australia. Methods A literature review was conducted using CINAHL, PubMed and Scopus in May 2015. The search terms were 'non-Indigenous researchers' AND 'Indigenous health research' and other combinations of these terms. Additional documents were sourced by hand using the reference lists of key articles. Results Seven thematic categories were identified: (1) Closing the Gap: implications for research; (2) history of Indigenous research; (3) developing Indigenous research using a capacity-building approach; (4) the cultural interface between Western paradigms and Indigenous knowledge; (5) ethical Indigenous research; (6) culturally safe Indigenous research; and (7) positive roles for non-Indigenous researchers in Indigenous research. Conclusion It is important that non-Indigenous researchers become more aware of culturally appropriate ways in which to undertake Indigenous research and to ensure that the research undertaken is safe, ethical and useful for participants. Fostering partnerships between non-Indigenous academic organisations and researchers and Indigenous health researchers is an important development that can promote and enhance the emerging field of Indigenous inquiry. Actively contributing to capacity building with Indigenous researchers and research initiatives is a key role that non-Indigenous researchers and academic institutions can have in improving Indigenous health. Self-determination through health research capacity building and evidence-based advocacy may provide the most useful outcomes for Indigenous people. What is known about the topic? The health status of Indigenous Australians is well below that of other Australians. Historically, research about Indigenous health has been undertaken by non-Indigenous researchers using Western research paradigms. There is a need to identify appropriate roles for non-Indigenous researchers supportive of culturally safe and ethical research. What does this paper add? This paper synthesises available knowledge about the role of non-Indigenous researchers with Indigenous health research and provides suggestions for their contribution to Indigenous research practice. What are the implications for practitioners? Non-Indigenous researchers need to: (1) focus on culturally safe research practices; (2) be willing to address power imbalances within the research process; and (3) advocate for change within academic institutions to support culturally safe research practices.

A prospective evaluation of first people's health promotion program design in the goulburn-murray rivers region

BACKGROUND

Aboriginal Community Controlled Organisations (ACCOs) provide community-focussed and culturally safe services for First Peoples in Australia, including crisis intervention and health promotion activities, in a holistic manner. The ecological model of health promotion goes some way towards describing the complexity of such health programs. The aims of this project were to: 1) identify the aims and purpose of existing health promotion programs conducted by an alliance of ACCOs in northern Victoria, Australia; and 2) evaluate the extent to which these programs are consistent with an ecological model of health promotion, addressing both individual and environmental determinants of health.

METHODS

The project arose from a long history of collaborative research. Three ACCOs and a university formed the Health Promotion Alliance to evaluate their health promotion programs. Local community members were trained in, and contributed to developing culturally sensitive methods for, data collection. Information on the aims and design of 88 health promotion activities making up 12 different programs across the ACCOs was systematically and prospectively collected.

RESULTS

There was a wide range of activities addressing environmental and social determinants of health, as well as physical activity, nutrition and weight loss. The design of the great majority of activities had a minimal Western influence and were designed within a local Aboriginal cultural framework. The most common focus of the activities was social connectedness (76 %). Physical activity was represented in two thirds of the activities, and nutrition, weight loss and culture were each a focus of about half of the activities. A modified coding procedure designed to assess the ecological nature of these programs showed that they recruited from multiple settings; targeted a range of individual, social and environmental determinants; and used numerous and innovative strategies to achieve change.

CONCLUSION

First Peoples' health promotion in the Goulburn-Murray Rivers region encompasses a broad range of social, cultural, lifestyle and community development activities, including reclaiming and strengthening cultural identity and social connectedness as a response to colonisation.

Australian Aboriginal and Torres Strait Islander-focused primary healthcare social and emotional wellbeing research: a systematic review protocol

BACKGROUND

Research with a focus on Aboriginal and Torres Strait Islander Australian's (hereafter referred to as Indigenous(1)) needs is crucial to ensure culturally appropriate evidence-based strategies are developed to improve health. However, concerns surrounding this research exist, arising from some previous research lacking community consultation, resulting in little community benefit or infringing on important cultural values. Values and Ethics: Guidelines for Ethical conduct in Aboriginal and Torres Strait Islander Health Research (hereafter referred to as Values and Ethics), developed by The National Health and Medical Research Council of Australia in 2003, is the ethical standard for Indigenous-focused health research. Researchers must address its Values in research design and conduct. However, its impact on research processes is unclear. Local Protocols should also be considered. This review aims to systematically examine practices related to Values and Ethics, Local Protocols and the processes of conducting Indigenous-focused primary healthcare research in collaboration with external researchers.

METHODS

The following electronic databases and grey literature will be searched (2003 to current): MEDLINE, EMBASE, CINAHL, Informit and HealthInfoNet--an Indigenous-specific research and program website. Indigenous-focused research will be included. Research must be conducted in one or more primary healthcare services, in collaboration with external researchers and with a focus on social and emotional well being. One reviewer will review titles and abstracts to remove obviously irrelevant research articles. Full-text research articles will be retrieved and independently examined by two reviewers. Data and quality assessment will be completed by one reviewer and verified by a second reviewer. Quality will be assessed using modified versions of established quality assessment tools.

DISCUSSION

This review will provide information on research processes and the impact of Values and Ethics on Indigenous-focused primary healthcare research, informing communities and primary healthcare staff around research practices, and researchers and policy makers of strengths and weaknesses of practice.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015024994.

Strengths and limitations of a tool for monitoring and evaluating First Peoples' health promotion from an ecological perspective

BACKGROUND

An ecological approach to health and health promotion targets individuals and the environmental determinants of their health as a means of more effectively influencing health outcomes. The approach has potential value as a means to more accurately capture the holistic nature of Australian First Peoples' health programs and the way in which they seek to influence environmental, including social, determinants of health.

METHODS

We report several case studies of applying an ecological approach to health program evaluation using a tool developed for application to mainstream public health programs in North America - Richard's ecological coding procedure.

RESULTS

We find the ecological approach in general, and the Richard procedure specifically, to have potential for broader use as an approach to reporting and evaluation of health promotion programs. However, our experience applying this tool in academic and community-based program evaluation contexts, conducted in collaboration with First Peoples of Australia, suggests that it would benefit from cultural adaptations that would bring the ecological coding procedure in greater alignment with the worldviews of First Peoples and better identify the aims and strategies of local health promotion programs.

CONCLUSIONS

Establishing the cultural validity of the ecological coding procedure is necessary to adequately capture the underlying program activities of community-based health promotion programs designed to benefit First Peoples, and its collaborative implementation with First Peoples supports a human rights approach to health program evaluation.

Public health programs as surrogates for social action in Suriname, South America

This paper addresses the merits of public health activism that advocates for social change in which health is the outcome of interest. We acknowledge that while efforts at the individual level are important, social network models consider the underlying mechanisms that lie outside the public health sector. This paper considers the inequitable health of Indigenous people who bear a disproportionate share of the negative health consequences due to economic development programs that follow an assimilation model. This paper discusses a combination of theoretical constructs to understand and solve the problems at hand. It concludes that while the attention paid to technological and behavioral solutions at the individual level yields important health outcomes, attention should also be paid to structural causes that address social, political and economic barriers to prevent disease, disability and premature death.

Aboriginal health research in the remote Kimberley: an exploration of perceptions, attitudes and concerns of stakeholders

Background

For decades Indigenous peoples have argued for health research reform claiming methods used and results obtained often reflect the exploitative history of colonisation. In 2006 the Kimberley Aboriginal Health Planning Forum (KAHPF) Research Subcommittee (hereafter, the Subcommittee) was formed to improve research processes in the remote Kimberley region of north Western Australia. This paper explores the major perceptions, attitudes and concerns of stakeholders in the Subcommittee.

Methods

Qualitative analysis was carried out on data retrospectively collected from multiple evidentiary sources linked to the Subcommittee i.e. database, documents, interviews, review forms and emails from 1 January 2007 to 31 October 2013.

Results

From 1 January 2007 to 30 June 2013 the Subcommittee received 95 proposals, 57 (60%) driven by researchers based outside the region. Local stakeholders (22 from 12 different Kimberley organisations) raised concerns about 36 (38%) projects, 30 (83%) of which were driven by external researchers. Major concerns of local stakeholders were inadequate community consultation and engagement; burden of research on the region; negative impact of research practices; lack of demonstrable community benefit; and power and control of research. Major themes identified by external stakeholders (25 external researchers who completed the review form) were unanticipated difficulties with consultation processes; barriers to travel; perceiving research as a competing priority for health services and time-consuming ethics processes. External stakeholders also identified strategies for improving research practices in the Kimberley: importance of community support in building good relationships; employing local people; flexibility in research approaches; and importance of allocating sufficient time for consultation and data collection.

Conclusions

Health research in the Kimberley has improved in recent years, however significant problems remain. Prioritising research addressing genuine local needs is essential in closing the gap in Indigenous life expectancy. The long-term aim is for local health service connected researchers to identify priorities, lead, conduct and participate in the majority of local health research. For this to occur, a more radical move involving reconceptualising the research process is needed. Changes to institutional timeframes and funding processes could improve Indigenous and community-based research.

Dietary practices and influences on diet intake among women in a Woodland Cree community

BACKGROUND

Overweight and obesity are increasing concerns among Aboriginal women, and lifestyle behaviours (i.e. dietary patterns and physical activity) are considered to be contributing factors. The present study aimed to explore the social, cultural, behavioural and environmental factors influencing diet intake from a trans-generational perspective and to characterise the dietary practices among Woodland Cree women.

METHODS

A mixed methods design using a concurrent triangulation approach explored the factors influencing diet intake and healthy eating among First Nations women on a reserve community in northern Saskatchewan, Canada. Dietary practices were assessed using 24-h recalls.

RESULTS

Dietary analysis revealed low intake of fruits and vegetables and milk and alternatives in the sample, with high intake of 'other' foods. Limited amounts of traditional food (TF) were reported. Taste primarily influenced food choice, with a preference for TF highlighted among older participants. Healthy eating was considered to be a health-promoting behaviour, yet a lack of availability, high costs and difficulties accessing various foods were the most noted barriers to healthy eating.

CONCLUSIONS

The dietary practices in this sample indicate the limited consumption and variety of TF and fruits and vegetables, and a high consumption of 'other' foods, which suggests inadequate intakes of various vitamins and nutrients. The findings from a trans-generational perspective highlight various barriers across the age groups that can substantially impact food choices, and reinforces the need for community and age-specific strategies to address issues of exposure, accessibility and affordability to nutritious foods that improve the diet and preserve cultural identity among residents living in reserve communities.

Rationale and design of the Kanyini guidelines adherence with the polypill (Kanyini-GAP) study: a randomised controlled trial of a polypill-based strategy amongst indigenous and non indigenous people at high cardiovascular risk

BACKGROUND

The Kanyini Guidelines Adherence with the Polypill (Kanyini-GAP) Study aims to examine whether a polypill-based strategy (using a single capsule containing aspirin, a statin and two blood pressure-lowering agents) amongst Indigenous and non-Indigenous people at high risk of experiencing a cardiovascular event will improve adherence to guideline-indicated therapies, and lower blood pressure and cholesterol levels.

METHODS/DESIGN

The study is an open, randomised, controlled, multi-centre trial involving 1000 participants at high risk of cardiovascular events recruited from mainstream general practices and Aboriginal Medical Services, followed for an average of 18 months. The participants will be randomised to one of two versions of the polypill, the version chosen by the treating health professional according to clinical features of the patient, or to usual care. The primary study outcomes will be changes, from baseline measures, in serum cholesterol and systolic blood pressure and self-reported current use of aspirin, a statin and at least two blood pressure lowering agents. Secondary study outcomes include cardiovascular events, renal outcomes, self-reported barriers to indicated therapy, prescription of indicated therapy, occurrence of serious adverse events and changes in quality-of-life. The trial will be supplemented by formal economic and process evaluations.

DISCUSSION

The Kanyini-GAP trial will provide new evidence as to whether or not a polypill-based strategy improves adherence to effective cardiovascular medications amongst individuals in whom these treatments are indicated.

TRIAL REGISTRATION

This trial is registered with the Australian New Zealand Clinical Trial Registry ACTRN126080005833347.

Ethics and governance of a longitudinal birth cohort

All longitudinal birth cohorts should be undertaken with a detailed ethical strategy and policy on governance. Here we outline the various factors that should be taken into consideration and describe ways in which these issues may be addressed.

Placing ethics in the centre: negotiating new spaces for ethical research in conflict situations

Issues of power and consent, confidentiality, trust, and benefit, risks to researchers, and potential harm to participants, are all contested when working with different cultures and within environments marked by violence and insecurity. Difficulty resolving these dilemmas may paralyse ethics committees, may fail to give the guidance sought by researchers, and will not help populations who are among the world's most vulnerable. Even where efforts are made to respond to ethical guidelines and to improve practice, considerable impediments are present in many developing countries, including lack of formal ethical review structures in unstable settings, lack of required skills, limited political and institutional recognition of ethical issues, competing interests, and limitations in clinical and research practice (Elsayed 2004, Macklin 2004). In conflict settings, these limitations are more marked, and the responsibilities of the researcher for ethical practice are greater, but the mechanisms for oversight are weaker. Moreover, the constant focus on vulnerabilities and problems, and the often almost total lack of recognition of strengths and resilience, can further disempower already exploited groups and individuals. The capacity of refugees and communities in conflict to take an active role in the research process is seldom acknowledged, and undermines the potential for more innovative research which can help generate the evidence for better policy and practice.

"If the land is healthy ... it makes the people healthy": the relationship between caring for Country and health for the Yorta Yorta Nation, Boonwurrung and Bangerang Tribes

This article reports on research undertaken with members of three Indigenous groups in Victoria, Australia, to explore the health and wellbeing implications of caring for Country (defined as having knowledge, sense of responsibility and inherent right to be involved in the management of traditional lands). The research findings provide a better understanding of this key determinant of the health and wellbeing of Indigenous people in the context of public health where there are few existing published studies assessing this relationship. Thirteen traditional custodians(1) and local Indigenous environmental workers were interviewed. This qualitative study involving semi-structured interviews identified that caring for Country offers great benefits, including building self-esteem, fostering self-identity, maintaining cultural connection and enabling relaxation and enjoyment through contact with the natural environment. Results generated indicate that caring for Country may offer a means of improving the current poor health status of Indigenous Australian peoples.

The Kalgoorlie Otitis Media Research Project: rationale, methods, population characteristics and ethical considerations

Otitis media (OM) is one of the most common paediatric illnesses for which medical advice is sought in developed countries. Australian Aboriginal children suffer high rates of OM from early infancy. The resultant hearing loss can affect education and quality of life. As numerous factors contribute to the burden of OM, interventions aimed at reducing the impact of single risk factors are likely to fail. To identify key risk factors and understand how they interact in complex causal pathways, we followed 100 Aboriginal and 180 non-Aboriginal children from birth to age 2 years in a semi-arid zone of Western Australia. We collected demographic, obstetric, socio-economic and environmental data, breast milk once, and nasopharyngeal samples and saliva on seven occasions. Ear health was assessed by clinical examination, tympanometry, transient evoked otoacoustic emissions and audiometry. We considered the conduct of our study in relation to national ethical guidelines for research in Aboriginal and Torres Strait Islander health. After 1 year of community consultation, the study was endorsed by local committees and ethical approval granted. Fieldwork was tailored to minimise disruption to people's lives and we provided regular feedback to the community. We saw 81% of non-Aboriginal and 65% of Aboriginal children at age 12 months. OM was diagnosed on 55% and 26% of routine clinical examinations in Aboriginal and non-Aboriginal children respectively. Aboriginal mothers were younger and less educated, fewer were employed and they lived in more crowded conditions than non-Aboriginal mothers. Sixty-four per cent of Aboriginal and 40% of non-Aboriginal babies were exposed to environmental tobacco smoke. Early consultation, provision of a service while undertaking research, inclusion of Aboriginal people as active members of a research team and appropriate acknowledgement will assist in ensuring successful completion of the research.

Building community involvement in cross-cultural Indigenous health programs

OBJECTIVE

To gain preliminary knowledge about issues identified by Native health investigators who would encourage greater community involvement in Indigenous health programs and research in Canada, Pacific Rim, and the United States.

DESIGN

A pilot/feasibility study, August 2001-April 2002.

SETTING

Indigenous health agencies and institutions in New Zealand, Australia, Canada, and the United States.

PARTICIPANTS

Thirty-six health professionals from rural and urban health centers participated, which resulted in 10 group and four individual interviews. Subjects included program managers, clinical physicians, and health researchers. Approximately 58% of the subjects self-identified as Indigenous.

RESULTS

Three overarching themes emerged from the interview data: (i) integration of cultural values of family and community into health provision; (ii) emphasis on health education and prevention programs for Indigenous youth; and (iii) indigenous recognition and self-determination in health delivery and research.

CONCLUSIONS

To improve and promote community involvement in primary health programs and services for Indigenous people involves a long-term social and political commitment to health protection on a national and an international level, as well as the understanding that research methodologies and health interventions must explicitly involve culturally appropriate values and behaviors that are implemented by Indigenous people.

'We are not just participants--we are in charge': the NACCHO ear trial and the process for Aboriginal community-controlled health research

OBJECTIVE

Methodological criteria that characterise ethically sound community-based studies are often described in overviews but are rarely documented in clinical studies. Research investigating the health of Aboriginal Australians is often small-scale, descriptive and largely driven by non-Indigenous people. The 'community-controlled' model of research relating to Aboriginal peoples health is a form of 'participatory' research that shifts the balance of control towards those being researched. This paper describes the methodological issues and principles that underpin community-controlled health research; their practical application; and encourages their adoption in research involving Indigenous populations.

DESIGN

Descriptive report of the methods used to conduct the landmark Aboriginal community-controlled multi-centre double-blind randomised controlled clinical ear trial investigating ototopical treatments for chronic suppurative otitis media.

RESULTS

The characteristics of the community-controlled research model are illustrated under the headings of: setting the research agenda; research project planning and approval; conduct of research; and analysis, dissemination and application of findings.

CONCLUSION

The 22 methodological elements which defined the community-controlled design of the ear trial may assist community groups, external research bodies and funding agencies to improve the acceptability, quality and scope of research involving Indigenous peoples. Aboriginal community-controlled organisations are well placed to lead research, which can be interventional and of a high scientific standard without compromising the values and principles of those being researched. With over 120 Aboriginal community-controlled health services (ACCHSs) across Australia, the potential exists for these services to engage in multi-centre research to realise solutions to health problems faced by Indigenous Australians.

Aboriginal and Torres Strait Islander health research and the conduct of longitudinal studies: issues for debate

The National Health and Medical Research Council, Research Agenda Working Group (RAWG), and the literature on Indigenous health have identified the need to fill gaps in descriptive data on Aboriginal and Torres Strait Islander health and noted both the lack of research with urban populations and the need for longitudinal studies. This paper presents some of the broad ethical and methodological challenges associated with longitudinal research in Indigenous health and focuses particularly on national studies and studies in urban areas. Our goal is to advance debate in the public health arena about the application of ethical guidelines and the conduct of longitudinal studies in Aboriginal and Torres Strait Islander communities. We encourage others to offer their experiences in this field.