Computerised Aboriginal and Torres Strait Islander health assessments in primary health care research

Abstract

There has been insufficient research involving Aboriginal and Torres Strait Islander peoples living in urban areas to inform strategies required to improve inequitable health outcomes and life expectancy for Aboriginal and Torres Strait Islander peoples. The injustice of these health inequities motivated me to investigate the use of computerised Aboriginal and Torres Strait Islander health assessments in primary care as a source of research data which can be used to respond to community priorities. I conducted this research at the Inala Indigenous Health Service, a Queensland Government funded primary health care service for Aboriginal and Torres Strait Islander peoples. Inala is a suburb in south- western Brisbane with a strong sense of community and identity, but also significant social and economic challenges. Staff at the Inala Indigenous Health Service have been using Aboriginal and Torres Strait Islander health assessments for both clinical and research purposes since their introduction in 2004 for adults, and 2006 for children.In this thesis, I used a mixed methods approach. The first two research projects of this thesis are situated in the postpositivist paradigm where researchers accept that scientific research produces evidence which helps establish the probability that a finding is true rather than truth itself. The first research project evaluated the feasibility of implementing computerised health assessments in primary care for dual clinical and research purposes. After finding that it was feasible, the second research project established that computerised health assessment data were sufficiently representative, complete, reliable, and valid to produce credible research findings.The final two research projects of this thesis are situated in the transformative paradigm with the explicit goal of improving the social world. I acknowledge that my position as a white, non-Indigenous, male, medical researcher influenced the conduct and outcome of all the research projects in this inquiry. To minimise the risk that this research would reproduce the damaging effects of research for Aboriginal and Torres Strait Islander peoples conducted by non-Indigenous researchers, I listened to community voices to inform my approach to research using computerised health assessment information.I conducted a qualitative study involving thematic analysis of semi-structured interviews with key informants in the Inala Aboriginal and Torres Strait Islander community regarding their priorities for health and research based on health assessment data. Rather than a discrete set of health priorities, key informants articulated an authoritative understanding of how interrelated, inter-generational, social, cultural, and environmental determinants of health operated in a “cycle” to influence the community’s health. Furthermore, some key informants were ambivalent about Aboriginal and Torres Strait Islander health assessments because of their biomedical emphasis. These findings supported the addition of questions to health assessments at the Inala Indigenous Health Service regarding psychosocial stressors, social determinants of health, and community participation. Because of key informants’ emphasis on the social determinants, I conducted an epidemiological investigation of social, cultural, and environmental determinants of health using adult computerised health assessment data. From this investigation, I found that the experience of a range of social, cultural, and environmental determinants of health varied significantly according to the age and sex of participants suggesting opportunities for demographically targeted policy intervention.Findings from this doctoral research demonstrate that Aboriginal and Torres Strait Islander computerised health assessments can be implemented in the primary health care setting, and used to produce credible research findings which respond to community priorities. Presently, the widespread application of computerised health assessment based research has been limited by commonly used general practice software systems in Australia which include non-customisable health assessments, and are not suited to research. At the Inala Indigenous Health Service, future research based on computerised health assessments will seek to further investigate social, cultural, and environmental determinants of health, and could include longitudinal analysis and data linkage.The results of key informant interviews and the investigation of social, cultural, and environmental determinants will be fed back to community organisations and health services as a community report. This community report was designed to assist community organisations and health services plan, monitor, advocate, and apply to policy makers for funding for activities, programs, and services to address social, cultural, and environmental determinants of health.This research also revealed tensions inherent in attempting to reconcile the health priorities of community key informants situated in the social world with a medical researcher, a health service setting, and research tool, the health assessment, all situated within the privileged biomedical model of health. By positioning research in this thesis in the transformative paradigm using a mixed methods approach, I endeavoured to acknowledge and explore these tensions. These research findings encourage a policy discourse which does not emphasise the biomedical model of health, but rather emphasises the importance of taking the holistic view of health expressed by both the National Aboriginal Health Statement Working Party and Inala Aboriginal and Torres Strait Islander key informants.