Indigenous Health Promotion Research Articles

Successes in sexual health communications development, programmatic implementation and evaluation in the Torres Strait region 2006 to 2012

Objective:To evaluate the Indigenous sexual health promotion program in the Torres Strait 2006–2012 that culminated in an education‐entertainment radio drama, Kasa Por Yarn (KPY). Methods:A mixed methods approach applied to unpublished program documents and program‐derived peer‐reviewed publications was utilised. Results:Early initiatives established a strong partnership with Torres Strait Islander stakeholders. Significant community engagement throughout ensured a positive process. Telephone survey data (n=100, TSI, 15–24 years) found: 95% had heard of KPY and 80% listened to 2 or more episodes (reach); 86% recalled storylines/characters (recall); and 54% talked about KPY to family/friends (resonance). There was improvement in sexual health knowledge scores (p<0.00) in the 15–19‐year‐old Torres Strait Islander population between 2007 and 2012. The 2012 15–24‐year‐old population exposed to KPY had higher sexual health knowledge scores compared with those unexposed (p=0.02). Conclusions:This is an uncommon comprehensive evaluation of population‐based sexual health communications strategies delivered over years in a remote Australian setting. The findings are encouraging but demonstrate that positive shifts take time and are incremental. Implications:In addition to clinical strategies, strategic and sustained investment in sexual health promotion expertise that leads community partnership and program development is required to reduce youth risk and prevent HIV/AIDS in remote populations.

The characteristics, implementation and effects of Aboriginal and Torres Strait Islander health promotion tools: a systematic literature search.

BackgroundHealth promotion by and with Aboriginal and Torres Strait Islander (hereafter Indigenous) Australians is critically important given a wide gap in health parity compared to other Australians. The development and implementation of step-by-step guides, instruments, packages, frameworks or resources has provided a feasible and low-resource strategy for strengthening evidence-informed health promotion practice. Yet there has been little assessment of where and how these tools are implemented or their effectiveness. This paper reviews the characteristics, implementation and effects of Indigenous health promotion tools.MethodsIndigenous health promotion tools were identified through a systematic literature search including a prior scoping study, eight databases, references of other reviews and the authors’ knowledge (n = 1494). Documents in the peer reviewed and grey literature were included if they described or evaluated tools designed, recommended or used for strengthening Indigenous Australian health promotion. Eligible publications were entered into an Excel spreadsheet and documented tools classified according to their characteristics, implementation and effects. Quality was appraised using the Dictionary for Effective Public Health Practice Project (EPHPP) and Critical Appraisal Skills Program (CASP) tools for quantitative and qualitative studies respectively.ResultsThe review found that Indigenous health promotion tools were widely available. Of 74 publications that met inclusion criteria, sixty (81%) documented tools developed specifically for the Indigenous Australian population. All tools had been developed in reference to evidence; but only 22/74 (30%) publications specified intended or actual implementation, and only 11/74 (15%) publications evaluated impacts of the implemented tools. Impacts included health, environmental, community, organisational and health care improvements. The quality of impact evaluations was strong for only five (7%) studies.ConclusionsThe small number and generally moderate quality of implementation and evaluation studies means that little is known about how tools work to strengthen Indigenous health promotion practice. The findings suggest that rather than continuing to invest in tool development, practitioners, policy makers and researchers could evaluate the implementation and effects of existing tools and publish the results. There is a need for long-term investment in research to review the current use of health promotion tools and the factors that are likely to enhance their implementation.

‘For the Life of Me, I Can't See Why Those Students were Let Go on So Long’: Educating the Educators, Aboriginal and Torres Strait Islander-Style

In 2008, almost 40% of Aboriginal and Torres Strait Islander students enrolled in the Graduate Diploma in Indigenous Health Promotion at The University of Sydney failed to complete the course. Although this was not considered unusual when compared to previous years, the decision was made to investigate why so many students struggled to meet the expectations of a course that was pedagogically progressive, culturally affirming, taught by highly regarded academics and strongly supported by the university and its stakeholders. A qualitative study using in-depth semi-structured interviews was conducted, and many complex and interrelated issues were explored. One issue that was raised both unexpectedly and emphatically by almost half the study participants who completed the course was the unintentional stifling of individual student effort and achievement through the development of co-dependent relationships between academic staff and students. This article presents the data relevant to this particular issue, reflects on the findings, and outlines some of the strategies implemented since this study commenced that have contributed to a healthy completion rate of 98% over the past 3 years.

Enduring dilemmas of Indigenous health

In this issue of the Journal (page 602), Taylor and colleagues present findings from their study of Indigenous participation in cardiac rehabilitation, 7 an important form of secondary prevention. Their study identified many barriers to participation, including the challenges associated with extended family responsibilities, the sociocultural inappropriateness of cardiac rehabilitation programs, and historical barriers to using mainstream services. The barriers they identified are recurring themes in many evaluations of Indigenous health promotion and health care services. 2-6 At the heart of these recurring themes are two central tensions of Indigenous development: the tension between cultural difference and statistical equality, and the problem of marginalised identities. For a range of historical, geographical, socioeconomic and cultural reasons, the conditions required for a “healthy life” as defined by Western society (including nutritious food, smoking cessation, and accessing mainstream health services) are found less often in Indigenous than non-Indigenous populations. While many Indigenous communities and individuals see this as a major problem, for others, unhealthy behaviour and conditions are a normal part of life. For some Indigenous people, the environments and behaviour linked to good health are associated with nonIndigenous society and akin to a “foreign” culture. They may even be seen as antithetical to an Indigenous identity. Medical anthropologist Kate Senior’s research at Ngukurr in the Northern Territory provides one example of this. In this Indigenous community, hygiene practices are associated with the missionaries who required mission residents to keep their houses spotless. One older woman told Senior that, “I tell my own daughter how to do it, but all she says is ‘we’re not Munanga [white] — we don’t want to live Munanga way’”. 8 Walking for exercise is similarly considered a Munanga behaviour and regarded with amusement. Others have also noted that the approach taken to hygiene interventions in Indigenous communities in the past promoted resistance to, rather than adoption of, health-promoting behaviour. 9 Taylor et al suggest that attitudes such as these may be due to social exclusion. As one of the Aboriginal patients in their study commented in regard to health services, the legacy of colonisation and discrimination is that “it remain[s] in the psyche of the Aboriginal people that mainstream services are only there for other people”. 7 In addition to social exclusion, others have argued that cultural difference plays a role in the “foreignness” of health services and healthy behaviour. A study of smoking in an Aboriginal community describes how integral the practice is to family interaction and ceremonial exchange, and how refusing to smoke can produce unbearable social isolation and friction — the “passing around and sharing of cigarettes is part of the social fabric of the community”. 10 Anthropologist Maggie Brady has shown that alcohol misuse is similarly integrated into Indigenous social practices and identities. 11 Such findings imply that calling for health-promoting change may mean changing the “social fabric” of some Indigenous communities. While some working in Indigenous health see this as a necessary and positive change, others are troubled by the thought that certain cultural practices may be compromised in the pursuit of good health. For example, there is debate over the role of “demand sharing” 12 (where Indigenous people are obliged to accommodate even unreasonable demands from their kin) in preventing improvements in health behaviour and socioeconomic status. An anthropological study found that some non-Indigenous researchers working in Indigenous health expressed concern that healthy lifestyles may require a rejection of such kinship obligations. 13 The overarching tension here is between respecting cultural difference and addressing disadvantage. 14 Regardless of whether one believes that aspects of Indigenous culture will be changed by efforts to improve health, many non-Indigenous people working in Indigenous health harbour fears of eroding Indigenous culture and repeating the mistakes of the assimilation era. 13

Two-way approaches to Indigenous mental health literacy

This study was designed to provide important new information about relapse prevention in Indigenous 1 people with chronic mental illness. It aimed to explore Indigenous mental health promotion with Aboriginal mental health workers (AMHW) in order to develop strategies for effective mental health intervention. The research was conducted in three remote Indigenous communities in the top end of the Northern Territory with AMHW. Assessment, psycho-education, and care-planning resources were developed with local AMHW through exploration of local Indigenous perspectives of mental health promotion. Qualitative research methods and an ethnographic approach were used to elicit information, and data included key informant interviews, participant observation, music, photography and story telling. The study confirms that Indigenous people in remote communities prefer to use story telling and local language, local artwork and local music to convey health information. It also confirms that family and local practitioners are key cultural informants and that indirect, holistic and ‘two-way’ messages are preferred.

Challenging our own practices in Indigenous health promotion and research

At the 2006 National Conference of the Australian Health Promotion, Māori academic and public health physician Dr Papaarangi Reid challenged us to critique our own practice and asked whether health promotion needs to be de-colonised. In this paper, one Indigenous and two non-Indigenous researchers working within the Aboriginal community controlled health sector reflect on ways in which research and health promotion interventions with Indigenous populations challenge or reinforce the very values that have led to the disadvantage, neglect and apathy experienced by Indigenous populations in the first place. While our practice is framed by the principles of Aboriginal self-determination and community control, we suggest that de-colonising is not so much about the need to invent new research methods nor to search for research methods in traditional Aboriginal culture; it is much more about values, processes and relationships. We recognise the need to challenge the deficit model in health promotion and research, and we do not want to inflict any more damage to the community, through reinforcing stereotypes, creating fear, or contributing to further bad press. We argue for adopting a methodology that shifts power and enables Indigenous people to frame research in ways they want it framed, and for taking a holistic approach and focusing on community strength and resilience.

Evaluating Australian Indigenous community health promotion initiatives: a selective review

Effective health promotion interventions are critical to addressing the health needs of Indigenous people. We reviewed published and unpublished evaluation reports between 2000 and 2005 to identify practice issues pertinent to evaluators of Aboriginal and Torres Strait Islander health promotion initiatives. While the review of the literature was not systematic it was sufficiently comprehensive to provide a snapshot of evaluation practice currently in place within the Australian context. We found that published evaluation literature infrequently referred to the utilisation of guidelines for ethical research with Aboriginal and Torres Strait Islander peoples. The implications of this are that the importance and relevance of the guidelines for evaluative research are not being widely promoted or disseminated to evaluation practitioners and the role of the guidelines for improving evaluation practice remain unclear. While many innovative health promotion programs appear to have been highly regarded and well received by communities, the evaluation studies were not always able to report conclusively on the impact and health outcomes of these interventions or programs. This was due mainly to limitations in evaluation design that in some cases were insufficiently robust to measure the complex and multifaceted interventions described. To enhance rigour, evaluators of community health promotion initiatives could utilise mixed method approaches overtly informed by appropriate ethical guidelines, together with a broader range of qualitative methods aided by critical appraisal tools to assist in the design of evaluation studies.

Searching for evidence: what works in Indigenous mental health promotion?

The high rates of mental health issues confronting Indigenous populations make it imperative that action to promote mental health and prevent the development of mental health problems is effective. An accumulating evidence base for mental health promotion now exists; however, it remains significantly underdeveloped for Indigenous groups. This paper outlines the key findings of a systematic review of the literature undertaken to identify attributes of effective Indigenous mental health promotion interventions. Conclusive evidence of the efficacy of Indigenous mental health promotion interventions could not be determined because the evidence base is limited. However, this review did highlight several important findings. First, there were few well-conducted intervention evaluations; in many, the design was weak and insufficient information was supplied to assess effectiveness. Second, Indigenous mental health promotion initiatives commonly focused on individual behaviour change, rather than the broader social, ecological or policy determinants. Third, many interventions involved extensive Indigenous participation, thus supporting cultural relevance and community involvement, essential for the future of Indigenous mental health promotion. There is insufficient evidence about effective mental health promotion and prevention interventions for Indigenous populations.

Strong in the City: towards a strength-based approach in Indigenous health promotion

Issue addressed: To describe the potential for strength-based approaches in health promotion with the example of an urban Indigenous community.

Editorial – Advancing Indigenous health

Introduction: Welcoe to this issue of the Health Promotion Journal of Australia, which focuses on Indigenous health promotion. More than a year ago, the Journal editors issued an invitation for authors to submit papers on any aspect of health promotion relating to Indigenous peoples; this issue is the result. The Editors' role in the process of reviewing, requesting revisions and the always difficult decision to reject a paper (given the work involved in preparing a manuscript) was assisted by the contributions of two Indigenous colleagues, Dr Lisa Jackson Pulver (University of New South Wales) and Mr Shane Hearn (University of Sydney).