Indigenous Health Program Research Articles

Factors of success, barriers, and the role of frontline workers in Indigenous maternal-child health programs: a scoping review

BackgroundDespite considerable investment in maternal-child programs in Canada, there has been little positive impact on the health of Indigenous mothers and their children. The reasons for this are unclear and there is a need to identify how such programs can be successfully implemented. Community input is essential for successful programs; however, it is unclear what the contributions of frontline workers have been in the health program process, i.e., program development, delivery, and evaluation. Based on these identified gaps, this scoping review aimed to: (1) identify factors of success and barriers to successful Indigenous maternal-child community health programs for mothers and their children aged 0–6 years; and (2) explore how frontline workers are included in the program process.MethodsThis scoping review was completed using the Arksey and O’Malley framework, informed by Levac et al. Four data bases (Medline, CINAHL, Embase, and Scopus), grey literature, and reference lists were searched for relevant materials from 1990–2019. Data was extracted from included articles and analysed using descriptive statistics, thematic analysis with the Braun and Clarke framework, and a Principal Component Analysis.ResultsForty-five peer-reviewed and grey articles were included in the review. Factors of program success included: relationship building; cultural inclusion; knowledge transmission styles; community collaboration; client-centred approaches; Indigenous staff; and operational considerations. Barriers included: impacts of colonization; power structure and governance; client and community barriers to program access; physical and geographical challenges; lack of staff; and operational deficits. Frontline workers were found to have a role in program delivery (n = 45) and development (n = 25). Few (n = 6) had a role in program evaluation.ConclusionAlthough a better understanding of the frontline worker role in maternal-child health programs was obtained from the review, in a large proportion of literature the authors could not determine if the role went beyond program delivery. In addition, no direct input from frontline workers and their perspectives on program success or barriers were identified, suggesting areas to explore in future research. This review's findings have been applied to inform a community-based participatory research project and may also help improve the development, delivery, and evaluation of Indigenous maternal-child health programs.

Culture Is Healing: Promising Practices and Impacts from an Urban Indigenous Youth-Led Health and Wellness Program

This article explores the integration of cultural continuity in health programs for Indigenous youth, leveraging insights from Indigenous Youth Wellness Facilitators, in the Culture Is Healing program. It identifies four practices and their impacts, strengthening community and identity among Indigenous youth. The findings provide valuable recommendations for practitioners and policymakers.

A scoping review of commissioning practices used in the evaluation of Indigenous health and wellbeing programs: Protocol article

Despite the billions of dollars invested in improving Indigenous health and wellbeing outcomes in Australia, there is little evidence of program effectiveness to inform policy and practice. The deficiency of evaluations is problematic. Critical to this process is the effective engagement of commissioners with Indigenous peoples, which is not well documented. Currently, there is scant evidence on modes of commissioning practices used. This scoping review will aim to identify the spectrum of commissioning practices used when evaluating Indigenous health and wellbeing programs in Australia, codifying them into a model set. Documents (between 2008 and 2020) will be retrieved from Scopus, Proquest, Informit, Google Scholar and via a web-based search that refers to the commissioning of Indigenous health and wellbeing program evaluations in Australia, New Zealand, Canada or the United States. Importantly, the research team is Indigenous-led and the project’s governance, quality and translation framework will be informed by a project advisory group, including Indigenous associates. This will be the first scoping review globally to identify practices used to commission Indigenous health and wellbeing program evaluations. Results will be utilised to strengthen the commissioning practices of Indigenous health and wellbeing programs in Australia and overseas.

Indigenous health and wellbeing program evaluation commissioning models: results from a scoping review

Indigenous health and wellbeing program evaluation commissioning models: results from a scoping review

Intertribal Collaboration and Health: A Literature Review.

In the United States, American Indians and Alaska Natives (AIAN) are rebuilding their nations through assertion of sovereignty, standards of governance, cultural frameworks, strategic orientation, and effective leadership. The approach emphasizes tribal self-determination in managing nation affairs and reducing reliance on state and federal assistance. Through nation-building, tribal nations can improve their citizens' health and well-being while empowering local capacity and cultural pride. Intertribal collaboration can be an effective strategy to leverage resources and create a coalition for support and knowledge exchange; however, the research documenting practices, and outcomes of tribal health management that uses intertribal collaboration is limited. This systematic review investigates health-focused collaborations among the tribal nations in North America. Peer-reviewed articles that included at least two federally recognized tribes, described AIAN driven initiatives, implemented a health management plan, collaborated between Indigenous leaders, and goals of social, behavioural, mental, and physical health outcomes were examined. This search was limited to articles published between January 1, 1970 to November 30, 2019. The PRISMA systematic review process was used. Twenty-seven articles were screened, and three articles were eligible for thematic review. The articles highlighted the importance of utilizing an Indigenous framework to facilitate program management and collaboration, recognition of cultural differences, and sovereignty rights. Characteristics that contributed to the establishment and strengthening of intertribal collaboration were: (1) adapt new proposals, (2) respectful recognition of sovereignty, and (3) transparent and honest communication. The small sample size indicated most Indigenous health programs are not "AIAN-driven", limiting the foundation for building evidence-based frameworks.

Looking forward looking black: making the case for a radical rethink of strategies for success in Indigenous higher education

Abstract This study takes a retrospective look at the educational experiences of Indigenous health professionals who graduated from The University of Queensland's Indigenous Health Program between 1994 and 2005, to understand the enablers for growing an Indigenous health workforce capable of advancing the health of Indigenous peoples. Drawing on the qualitative accounts of 31 students and 9 staff members, this paper examines the enablers to educational success at this time, juxtaposed against current Indigenising agendas in higher education, of aspiration and capacity building alongside the task of embedding Indigenous knowledges within curricula. We look back not as a call to return to Indigenous-specific cohort courses but rather reconsider both the measures of and strategies for success in Indigenous higher education, within health and beyond, interrogating the ideological assumptions that inform them.

Decolonising the commissioning of Indigenous health and wellbeing program evaluations in Australia

Abstract Background Significant financial investments have been made to improve the life expectancy gap between Indigenous people and other Australians over the last 10 years. Despite the investment, few evaluations have been commissioned to assess program effectiveness. Indigenous leaders have been calling for a more active role in the commissioning of Indigenous program evaluations. This project aims to identify how government and non-government commissioning practices can better support Indigenous engagement and leadership in the evaluation of health and wellbeing programs in Australia. This presentation reports on the different commissioning models that support Indigenous program evaluations, from the perspectives of commissioners, evaluators and program providers. Methods Semi-structured interviews were conducted with 20 Indigenous and non-Indigenous commissioners, evaluators and program providers. A mixed coding procedure was used. Interviews were coded using deductively derived codes reflecting best practice principles in Indigenous evaluation and inductively derived codes from participant stories. Interviews were analysed using NVivo qualitative software. A collaborative group-based approach to data analysis was used guided by Indigenous Standpoint Theory. Results The commissioning of Indigenous-specific program evaluations in Australia reflects top-down, participatory, co-design and Indigenous-led approaches. Top-down approaches were considered 'extractive' and had limited or token Indigenous input. Indigenous models were more strongly aligned with best practice and reflected authentic Indigenous engagement. There was agreement across the stakeholder groups on the value of Indigenous engagement in the commissioning process. The presentation will elaborate on the different approaches, their characteristics, strengths/ limitations. Conclusions Diverse approaches to commissioning are used and reflect different levels of Indigenous engagement and leadership. Key messages In the commissioning of Indigenous evaluations there needs to be governance structures to support Indigenous engagement. In the commissioning of Indigenous evaluations there needs to be greater input by Indigenous people.

Action research to implement an Indigenous health curriculum framework

In recent decades Indigenous health curriculum frameworks have been developed, however, few studies about their implementation exist. This study aimed to employ critical theory and action research to understand how an Indigenous health curriculum framework could be applied and associated learning and teaching iteratively improved. Three action research cycles where conducted from 2017 to 2019. Student reaction (satisfaction and engagement) was collected via survey 2017–2019. Student learning was collated 2018–2019 via self-perception survey (knowledge, attitude, confidence, commitment); multi-choice questions (knowledge) and; content analysis of apply and analyse activities (skill). The teaching team met annually to reflect on findings and plan enhancements to learning and teaching. Over 2017–2019 there was a pattern of improved student reaction and learning. Connecting this research to Faculty level committees led to widening success and improved sustainability of the practice. The online unit and workshop delivery were scalable, overcame a barrier of educator skill and confidence to teach this area, allowed for quality content control and provided data for analysis. Interestingly, learning gained from this unit matched that described as occurring from student placements in health settings with high numbers of Indigenous people. Student learning occurred across the Framework three levels (novice, intermediate and entry to practice) suggesting that the taxonomy of the Framework does not necessarily align with the reality of learning and teaching. Vertical implementation of the five learning domains would benefit from alignment with training evaluation models and validated assessment to understand learning that has occurred rather than the teaching that has been taught. In this study health profession accreditation bodies had driven the imperative for an Indigenous health program and curriculum. Research on Indigenous health learning and teaching relating to behaviour and results in workplaces is needed.

Indigenous Health Service Evaluation: Principles and Guidelines from a Provincial “Three Ribbon” Expert Panel

Abstract: A group of Indigenous health and social service evaluators called the “Three Ribbon” panel came together in Toronto in 2015/16 with the goal of informing a set of evidence-based guidelines for urban Indigenous health and social service and program evaluation. The collective knowledge and experiences of the Three Ribbon panel was gathered through discussion circles and synthesized around the following areas: barriers to conducting Indigenous health and social service evaluation; decolonizing principles and protocols that support community self-determination and centralize Indigenous culture and worldviews; and guidelines to inform health and social service evaluation moving forward. The wisdom and contributions of the Three Ribbon Panel creates space for Indigenous worldviews, values, and beliefs within program evaluation practice and has important implications for evaluation research and application.

Strategies to support culturally safe health and wellbeing evaluations in Indigenous settings in Australia and New Zealand: a concept mapping study

BackgroundIn recent decades, financial investment has been made in health-related programs and services to overcome inequities and improve Indigenous people’s wellbeing in Australia and New Zealand. Despite policies aiming to ‘close the gap’, limited evaluation evidence has informed evidence-based policy and practice. Indigenous leaders have called for evaluation stakeholders to align their practices with Indigenous approaches.MethodsThis study aimed to strengthen culturally safe evaluation practice in Indigenous settings by engaging evaluation stakeholders, in both countries, in a participatory concept mapping study. Concept maps for each country were generated from multi-dimensional scaling and hierarchical cluster analysis.ResultsThe 12-cluster Australia map identifies four cluster regions: An Evaluation Approach that Honours Community; Respect and Reciprocity; Core Heart of the Evaluation; and Cultural Integrity of the Evaluation. The 11-cluster New Zealand map identifies four cluster regions: Authentic Evaluation Practice; Building Māori Evaluation Expertise; Integrity in Māori Evaluation; and Putting Community First. Both maps highlight the importance of cultural integrity in evaluation. Differences include the distinctiveness of the ‘Respecting Language Protocols’ concept in the Australia map in contrast to language being embedded within the cluster of ‘Knowing Yourself as an Evaluator in a Māori Evaluation Context’ in the New Zealand map. Participant ratings highlight the importance of all clusters with some relatively more difficult to achieve, in practice. Notably, the ‘Funding Responsive to Community Needs and Priorities’ and ‘Translating Evaluation Findings to Benefit Community’ clusters were rated the least achievable, in Australia. The ‘Conduct of the Evaluation’ and the ‘Prioritising Māori Interests’ clusters were rated as least achievable in New Zealand. In both countries, clusters of strategies related to commissioning were deemed least achievable.ConclusionsThe results suggest that the commissioning of evaluation is crucial as it sets the stage for whether evaluations: reflect Indigenous interests, are planned in ways that align with Indigenous ways of working and are translated to benefit Indigenous communities Identified strategies align with health promotion principles and relational accountability values of Indigenous approaches to research. These findings may be relevant to the commissioning and conduct of Indigenous health program evaluations in developed nations.

Arterial Compliance is Improved Following a Community-led 12-week Indigenous Wholistic Health and Wellness Program

Arterial Compliance is Improved Following a Community-led 12-week Indigenous Wholistic Health and Wellness Program

Akiikaa (it is the land): exploring land-based experiences with university students in Ontario.

Indigenous learning traditionally comes from the land. Akiikaa ('it is the land' in Algonkian) is designed to assist graduate students in thinking beyond the classroom and understanding the elements of life as known by Indigenous people to live a healthy life. Akiikaa will provide graduate students (both Indigenous and non-Indigenous) with opportunities to learn about Indigenous ways of knowing. They will learn from an instructor, Elders and their peers about how the land is an instrumental part of all aspects of Indigenous life including health and well-being. One of the goals of the Master of Public Health in Indigenous Health program (at the University of Toronto) and the land-based experiences is to shift the thinking away from humans being the dominating force on Mother Earth to equality amongst all aspects of life. Graduate students are introduced to 'personhood' rights for plants, animals, water, and air, which is a shift from the current World Health Organization's view of public health that builds upon a population health approach but neglects the elements that surround humans as necessary for living a healthy life. It has been suggested that Indigenous land-based education acts as a method of decolonization through reclamation of Indigenous ideology and use of land. Land and land experience are highly prized by Indigenous people around the world as cultures and languages are based on the interaction of people with nature/land. This move to delivering the curriculum in the natural environment using Indigenous knowledges as its pedagogy is anticipated to change attitudes about Indigenous people and issues as well as improving the health and well-being of graduate students and, over time, Indigenous peoples' health and well-being.

Indigenous health: designing a clinical orientation program valued by learners

BackgroundIndigenous health programs are seen as a curriculum response to addressing health disparities and social accountability. Several interrelated teaching approaches to cultural competency curricula have been recommended, however evidence of the impact of these on learner outcomes including engagement and self-reported competencies is limited. We aimed to explore undergraduate medical student perspectives of an indigenous health orientation program to inform curriculum strategies that promote learning and development of clinical skills.MethodsWe analyzed quantitative and qualitative student evaluations (n = 602) of a three-day immersed indigenous health orientation program between 2006 and 2014 based on Likert-scale responses and open-text comments. We conducted a thematic analysis of narrative student experiences (n = 426).ResultsOverall, 509 of 551 respondents (92%) rated the indigenous health orientation program as extremely or highly valuable and most (87%) reported that the course strongly increased their interest in indigenous health. The features of the clinical course that enhanced value for learners included situated learning (learning environment; learning context); teaching qualities (enthusiasm and passion for Māori health; role-modelling); curriculum content (re-presenting Māori history; exploring Māori beliefs, values and practices; using a Māori health framework in clinical practice); teaching methodologies (multiple teaching methods; simulated patient interview); and building relationships with peers (getting to know the student cohort; developing professional working relationships).ConclusionsUndergraduate medical students valued an indigenous health program delivered in an authentic indigenous environment and that explicitly reframed historical notions of indigenous health to contextualize learning. Content relevant to clinical practice, faculty knowledge, and strengthened peer interactions combined to build learner confidence and self-reported indigenous health competencies. These findings suggest empirical evidence to support a curriculum approach to indigenous health teaching that enhances clinical learning.

Indigenous health program evaluation design and methods in Australia: a systematic review of the evidence

Objective:Indigenous Australians experience a disproportionately higher burden of disease compared to non‐Indigenous Australians. High‐quality evaluation of Indigenous health programs is required to inform health and health services improvement. We aimed to quantify methodological and other characteristics of Australian Indigenous health program evaluations published in the peer‐reviewed literature. Methods:Systematic review of peer‐reviewed literature (November 2009–2014) on Indigenous health program evaluation. Results:We identified 118 papers describing evaluations of 109 interventions; 72.0% were university/research institution‐led. 82.2% of evaluations included a quantitative component; 49.2% utilised quantitative data only and 33.1% used both quantitative and qualitative data. The most common design was a before/after comparison (30.5%, n=36/118). 7.6% of studies (n=9/118) used an experimental design: six individual‐level and three cluster‐randomised controlled trials. 56.8% (67/118) reported on service delivery/process outcomes (versus health or health risk factor outcomes) only. Conclusions:Given the number of Indigenous health programs that are implemented, few evaluations overall are published in the peer‐reviewed literature and, of these, few use optimal methodologies such as mixed methods and experimental design. Implications for public health:Multiple strategies are required to increase high‐quality, accessible evaluation in Indigenous health, including supporting stronger research‐policy‐practice partnerships and capacity building for evaluation by health services and government.

Interculturalidad en Salud: Reflexiones a partir de una Experiencia Indígena en la Amazonia Peruana

This article examines the main characteristics of the proposal on interculturality developed by an indigenous Amazonian organization of Peru for the training of indigenous youth as nurse technicians in intercultural health. It shows how the Interethnic Association for the Development of the Peruvian Jungle (Aidesep) appropriates the concept of interculturality, reconfigures and reconstructs it. Based on internal documents, institutional publications, testimonies of graduates of the intercultural health program, leaders and members of the technical team of the Indigenous Health Program of AIDESEP, we analyze the construction and implementation of the concept of interculturality. We also examin the way in which an indigenous organization becomes a proponent of interculturality, building an indigenous response for the training of health professionals prepared to provide culturally appropriate health services to the indigenous population. The proposal for the training of nurse technicians in intercultural health shows that it is possible for critical interculturality to move from discourse to practice when indigenous peoples develop their own intercultural proposals.

A Atuação das Comissões Intergestores Bipartite de Minas Gerais e Rio de Janeiro frente ás necessidades de Saúde (2012-2013)

Introdução: O presente artigo tem como objetivo verificar a atuação das Comissões Intergestores Bipartite de Minas Gerais e do Rio de Janeiro frente as especificidades de saúde locais nos anos de 2012 e 2013. Método: Apresenta uma pesquisa qualiquantitativa por meio da análise documental das Resoluções das Comissões Intergestores Bipartite dos estados disponíveis na internet por meio dos sites eletrônicos. Resultados: Através da análise comparativa realizada com os dados obtidos é possível concluir que ambos os estados possuem especificidades locais distintas, sendo o destaque de Minas Gerais programas estaduais voltados para a Saúde Indígena e o do Rio de Janeiro ações voltadas para a melhoria da Atenção Especializada. Conclusão: As Comissões Intergestores Birpatite têm desempenhado um papel fundamental na formulação de políticas públicas visando a melhoria de saúde da população, de acordo com os princípios do Sistema Único de Saúde (SUS). Com isso, os resultados desse estudo poderão servir de orientação para as Comissões dos estados na formulação de novas políticas.

The effectiveness of implementation in Indigenous Australian healthcare: an overview of literature reviews.

BackgroundEffective implementation can maximise the beneficial impacts of health services. It is therefore important to review implementation in the context of Indigenous populations, who suffer some of the greatest disadvantage within developed countries. This paper analyses Aboriginal and Torres Strait Islander (hereafter Indigenous) Australian health implementation reviews to examine the research question: What is the effectiveness of implementation, as reported in the Indigenous Australian health implementation literature?MethodsEight databases were systematically searched to find reviews of Indigenous Australian health services and/or programs where implementation was the focus. Search terms included Aborigin* OR Indigen* OR Torres AND health AND service OR program* OR intervention AND implementation (or like terms) AND Australia AND review. Review findings were analysed through the lens of the PARiHS framework which theorises that successful implementation occurs through the interplay of evidence, context and facilitation. The review followed Cochrane methods but was not registered.ResultsSix reviews were found; these encompassed 107 studies that considered health service/program implementation. Included studies described many health services implemented across Australia as not underpinned by rigorous impact evaluation; nevertheless implementers tended to prefer evidence-based interventions. Effective implementation was supported by clearly defined management systems, employment of Indigenous health workers as leaders, community control, partnerships, tailoring for diverse places and settings; and active facilitation methods. Short-term funding meant most studies focused on implementation in one site through pilot initiatives. Only two mentioned cost effectiveness. Indigenous Australian studies incorporated two elements not included in the PARiHS reference guide: the value of community control and equity of service provision across sites.ConclusionsComparison of the Indigenous Australian review findings against the PARiHS reference guide elements suggested a fledgling but growing state of Indigenous implementation research, and considerable scope to improve the effectiveness of implementation. Further research is required to explore Indigenous people’s understandings of what is important in healthcare implementation; particularly in relation to the value of community control and equity issues.

Empowering families by engaging and relating Murri way: a grounded theory study of the implementation of the Cape York Baby Basket program.

BackgroundEvaluating program outcomes without considering how the program was implemented can cause misunderstandings and inefficiencies when initiating program improvements. In conjunction with a program evaluation, reported elsewhere, this paper theorises the process of implementing an Indigenous Australian maternal and child health program. The Baby Basket program was developed in 2009 for the remote Cape York region and aimed to improve the attendance and engagement of Indigenous women at antenatal and postnatal clinics through providing three baskets of maternal and baby goods and associated health education.MethodsConstructivist grounded theory methods were used to generate and analyse data from qualitative interviews and focus groups with Indigenous women who received the baskets, their extended family members, and healthcare workers who delivered them. Data was coded in NVivo with concepts iteratively compared until higher order constructs and their relationships could be modelled to explain the common purpose for participants, the process involved in achieving that purpose, key strategies, conditions and outcomes. Theoretical terms are italicised.ResultsProgram implementation entailed empowering families through a process of engaging and relating Murri (Queensland Indigenous) way. Key influencing conditions of the social environment were the remoteness of communities, keeping up with demand, families’ knowledge, skills and roles and organisational service approaches and capacities. Engaging and relating Murri way occurred through four strategies: connecting through practical support, creating a culturally safe practice, becoming informed and informing others, and linking at the clinic. These strategies resulted in women and families taking responsibility for health through making healthy choices, becoming empowered health consumers and advocating for community changes.ConclusionsThe theoretical model was applied to improve and revise Baby Basket program implementation, including increased recognition of the importance of empowering families by extending the home visiting approach up to the child’s third birthday. Engaging and relating Murri way was strengthened by formal recognition and training of Indigenous health workers as program leaders. This theoretical model of program implementation was therefore useful for guiding program improvements, and could be applicable to other Indigenous maternal and child health programs.

Indigenous Health Program Abstracts

Indigenous Health Program Abstracts

Establishing the value of Indigenous eye health programs: health needs, economic priority and performance assessment approaches

The aim of this paper was to compare three different approaches that are used in support of additional funding of health programs, using Indigenous eye health programs (IEHPs) as an example. These approaches are Heath and Health Care Needs, Economic Priority (Value for Money) and Conformity with Health Services Performance Standards. A review of relevant literature was conducted to identify relevant benchmarks and assess IEHPs. In terms of health needs, vision loss is the fourth highest contributor to the Indigenous health gap. Additional funding for Indigenous eye treatment services to remove the gap is estimated at A$28.1million per annum. As an economic priority, IEHPs (specifically for refractive error, cataract, diabetic retinopathy and trachoma) demonstrate excellent value for money and compare favourably with other better-researched health programs. Evaluation of health performance measures indicated that IEHPs also perform well, as judged by Australian performance standards for health services generally and Indigenous health services more specifically, the later involving local delivery, including care coordination through Aboriginal-controlled community health services. The value of IEHPs was demonstrated using all three approaches. Different approaches are likely to be more or less persuasive with different audiences. The application of these approaches is relevant to other health programs. WHAT IS KNOWN ABOUT THIS TOPIC? Supporters of additional funding for health programs frequently use the impact of this additional funding on the health and health care needs of the affected populations and individuals. Indigenous Eye Health programs are considered for illustrative purposes. This argument is not necessarily persuasive to funders of health programs. WHAT DOES THIS PAPER ADD? This paper demonstrates that two further approaches, namely Economic Priority and Conformity with Health Performance Measure Standards, both demonstrate good arguments in support of additional funding and that these outcomes may be more persuasive to funders of health programs. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS? Practitioners are able to harness additional approaches with a higher likelihood of success of submissions for additional funding for the program they are promoting.