Brief intervention resource kits for Indigenous Australians: generally evidence‐based,but missing important components

Objective : Little is known about the content and quality of brief intervention kits specifically targeting SNAP risk factors (smoking, poor nutrition, alcohol misuse or physical inactivity) among Indigenous Australians. This paper reviews the type and quality of these kits. Methods : Brief intervention kits were primarily identified by contacting 74 health‐related organisations in Australia between 1 February 2007 and 4 March 2007. Results : Ten brief intervention kits met inclusion criteria: four targeted smoking; three targeted alcohol; one targeted alcohol, smoking and other drugs; one targeted alcohol, other drugs and mental health; and one targeted all SNAP risk factors. Brief intervention kits were reviewed using criteria developed from clinical guidelines for SNAP risk factors and guidelines for evaluating health promotion resources. Three kits met all review criteria. Five kits were consistent with evidence‐based guidelines, but lacked a training package, patient education materials and/or behavioural change strategies. All kits used images and language identifiable with Indigenous Australia, however, their cultural appropriateness for Indigenous Australians remains unclear. Conclusions and implications : The specific content of the missing components should be guided by the best‐available evidence, such as established mechanisms for health care provider feedback to patients as a behaviour change strategy, as well as the needs and preferences of health care providers and patients.     

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.     

‘We don't tell people what to do’: ethical practice and Indigenous health promotion

Health promotion aspires to work in empowering, participatory ways, with the goal of supporting people to increase control over their health. However, buried in this goal is an ethical tension: while increasing people's autonomy, health promotion also imposes a particular, health promotion‐sanctioned version of what is good. This tension positions practitioners precariously, where the ethos of empowerment risks increasing health promotion's paternalistic control over people, rather than people's control over their own health. Herein we argue that this ethical tension is amplified in Indigenous Australia, where colonial processes of control over Indigenous lands, lives and cultures are indistinguishable from contemporary health promotion ‘interventions’. Moreover, the potential stigmatisation produced in any paternalistic acts ‘done for their own good’ cannot be assumed to have evaporated within the self‐proclaimed ‘empowering’ narratives of health promotion. This issue's guest editor's call for health promotion to engage ‘with politics and with philosophical ideas about the state and the citizen’ is particularly relevant in an Indigenous Australian context. Indigenous Australians continue to experience health promotion as a moral project of control through intervention, which contradicts health promotion's central goal of empowerment. Therefore, Indigenous health promotion is an invaluable site for discussion and analysis of health promotion's broader ethical tensions. Given the persistent and alarming Indigenous health inequalities, this paper calls for systematic ethical reflection in order to redress health promotion's general failure to reduce health inequalities experienced by Indigenous Australians.     

Smoking, nutrition, alcohol and physical activity interventions targeting Indigenous Australians: rigorous evaluations and new directions needed

Objective: To describe and critique methodological aspects of interventions targeting reductions in smoking, poor nutrition, alcohol misuse and physical inactivity (SNAP risk factors) among Indigenous Australians. Methods: An electronic search of eight databases and a manual search of reference lists of literature reviews and reference libraries for Indigenous‐specific intervention studies published in peer‐reviewed journals (January 1990 to August 2007) were undertaken. Alcohol, smoking, nutrition or physical activity needed to be the primary focus of the study and the intervention needed to specifically target Indigenous Australians. Results: Twenty studies were selected for inclusion in the review. Methodologically, few studies employed randomisation or a control group, most omitted important details (e.g. costs), some did not report process measures (e.g. attrition rates), and some did not use validated measures. Two‐thirds of interventions were implemented at the community level and employed multiple strategies. Conclusion: There is a need for more rigorous evaluations of interventions targeting reductions in SNAP risk factors among Indigenous Australians, and to establish the reliability and validity of measures to quantify their effect. Implications: It may be beneficial for future Indigenous‐specific intervention research to focus on the evaluation of secondary prevention to complement the current concentration of effort targeting primary prevention. Community‐wide interventions, combining strategies of greater intensity for high risk individuals with those of less intensity targeting lower risk individuals, might also offer considerable promise.     

A review of tobacco interventions for Indigenous Australians

OBJECTIVE: To conduct a review of interventions to reduce the harm resulting from tobacco use among Indigenous Australians and to discuss the likely effect of a range of tobacco interventions if conducted in this population. METHODS: A systematic review of medical literature and an audit of information from 32 government departments, non-government organisations and indigenous health organisations, which was completed in March 2001. RESULTS: A number of small tobacco programs had been conducted. Only four tobacco interventions had been evaluated in indigenous communities: a trial of training health professionals in conducting a brief intervention for smoking cessation; a trial of a CD-ROM on tobacco for use with indigenous schoolchildren; a qualitative evaluation of the effect of a mainstream advertising campaign on Indigenous people; and a pilot study of smoke-free workplaces, evaluated by qualitative methods. None of these studies assessed smoking cessation as an outcome. Two of these studies were unable to conclusively show any effect of the interventions; training health professionals in delivering a brief intervention resulted in some changes to practice and the evaluation of the mainstream advertising campaign showed that following the campaign, knowledge about tobacco had increased. CONCLUSIONS: There was a major lack of research on and evaluation of tobacco interventions for Indigenous Australians. IMPLICATIONS: More research and evaluation is required to ensure that tobacco interventions are appropriate and effective for Indigenous people. It is time to cease chronicling the ill health of Indigenous Australians and time to ensure the availability of well-evaluated, effective tobacco programs.     

Engineering behaviour change in an epidemic: the epistemology of NIH‐funded HIV prevention science

Social scientific and public health literature on National Institutes of Health‐funded HIV behavioural prevention science often assumes that this body of work has a strong biomedical epistemological orientation. We explore this assumption by conducting a systematic content analysis of all NIH‐funded HIV behavioural prevention grants for men who have sex with men between 1989 and 2012. We find that while intervention research strongly favours a biomedical orientation, research into the antecedents of HIV risk practices favours a sociological, interpretive and structural orientation. Thus, with respect to NIH‐funded HIV prevention science, there exists a major disjunct in the guiding epistemological orientations of how scientists understand HIV risk, on the one hand, and how they engineer behaviour change in behavioural interventions, on the other. Building on the extant literature, we suggest that the cause of this disjunct is probably attributable not to an NIH‐wide positivist orientation, but to the specific standards of evidence used to adjudicate HIV intervention grant awards, including randomised controlled trials and other quantitative measures of intervention efficacy.     

Culture and healthy lifestyles: a qualitative exploration of the role of food and physical activity in three urban Australian Indigenous communities

Objective: 1) To explore the links between Indigenous Australian children's perspectives on culture, and healthy lifestyle behaviours. 2) To provide insight into how to approach the development of a health intervention targeting lifestyle behaviours in Australian Indigenous children. Methods: Seven semi‐structured focus groups sessions were conducted with Australian Indigenous children aged 5–12 years living on the South Coast of New South Wales. Audio‐recordings were transcribed and thematic analyses were conducted and related to principles of grounded theory. Results: Participants had connections to aspects of Australian Indigenous culture that were embedded in their everyday lives. Healthy lifestyle behaviours (such as healthy eating and physical activity) were found to be interconnected with Australian Indigenous culture and positive emotional wellbeing was identified as an important outcome of connecting Australian Indigenous children to cultural practices. Conclusion: Understanding the importance of culture and its role in healthy lifestyles is critical in the development of health interventions for Indigenous populations. Implication: Health interventions embedded with Australian Indigenous culture may have potential to improve physical and emotional health within Australian Indigenous communities. However, it is unlikely that a ‘one size fits all’ approach to health interventions can be taken.     

The design of behavioural interventions labelled as patient‐mediated: A scoping review

Objective

Patient‐mediated interventions (PMIs) directed at patients and/or physicians improve patient or provider behaviour and patient outcomes. However, what constitutes a PMI is not clear. This study described interventions explicitly labelled as “patient‐mediated” in primary research.

Methods

MEDLINE, EMBASE, Allied and Complementary Medicine, PsychINFO, HealthSTAR, Social Work Abstracts, CINAHL and Cochrane Library were searched from inception on 1 January 2017 for English language studies that developed or evaluated behavioural interventions referred to as “patient‐mediated” or “patient mediated” in the full text. Screening and data extraction were independently duplicated. Data were extracted and summarized on study and intervention characteristics. Interventions were categorized as 1 of 4 PMI pathways.

Results

Eight studies (4 randomized controlled trials, 1 observational study and 3 qualitative studies) were included. No studies explicitly defined PMI, and few PMIs were described in terms of content and format. Although 3 studies employed physician interventions, only patient interventions were considered PMIs. One study achieved positive improvement in patient behaviour.

Conclusions

Research is needed to generate consensus on the PMI concept, employ theory when designing or evaluating PMIs, establish the effectiveness of different types of PMIs, and understand when and how to employ PMIs alone or combined with other interventions.     

An explorative evaluation study of the mechanisms underlying a community‐based fitness centre in Denmark – Why do residents participate and keep up the healthy activities?

Health‐risk behaviour like physical inactivity is more evident in deprived neighbourhoods than in nondeprived neighbourhoods, and in the former knowledge is lacking as to what causes effects in interventions on physical activity. A possible contribution to physical activity interventions is community engagement, which has been shown to be effective for changing health‐risk behaviour, but more knowledge is needed on “the active ingredients” or mechanisms that make interventions work. The aim of this study was to give more insight into the possible mechanisms within an intervention on physical activity using community engagement. The study applied a theory‐based evaluation approach using theory of change to uncover the underlying mechanisms of a community‐based fitness centre in a deprived Danish neighbourhood. Data were gathered from documents about the intervention, semistructured interviews with three front‐line workers on the intervention and ten residents participating in the centre as either volunteer instructors or members. The following mechanisms of the intervention to improve participation and health were anticipated by the front‐line workers; the creation of meaningful communities through social interaction, the presence of relatable role models, residents taking responsibility and feeling co‐ownership and the experience of being of value as an instructor. Interviews with members and volunteer instructors showed that the anticipated mechanisms did facilitate participation and improved health; however, with some individual variations and with the physical and mental benefits of the particular activities also functioning as mechanisms for participation and engagement. Furthermore, the study found potential unintended consequences related to engagement, such as difficulties in balancing the needs of others with own needs. Findings indicate that both the social aspect and the activities should be prioritised, as should a continued focus on the inclusion of different residents in the area. Furthermore, unintended consequences should be considered and prevented through support for volunteering residents.     

Epidemiology of alcohol‐related burden of disease among Indigenous Australians

Objective: To compare the burden of alcohol‐related harm and underlying factors of this harm, by age and sex, for Indigenous and general population Australians. Methods: Population attributable fractions are used to estimate the disability adjusted life years (DALYs) for alcohol‐related disease and injury. The DALYs were converted to rates per 1,000 by age and sex for the Indigenous and general populations. Results: Homicide and violence rates were much higher for Indigenous males: greatest population difference was for 30–44 years, Indigenous rate 8.9 times higher. Rates of suicide were also greater: the largest population difference was for 15–29 years, Indigenous rate 3.9 times higher. Similarly, for Indigenous females, homicide and violence rates were much higher: greatest population difference was for 30–44 years, Indigenous rate 18.1 times higher. Rates of suicide were also greater: the largest population difference was for 15–29 years, Indigenous rate 5.0 times higher. Conclusions: Alcohol consumption and associated harms are of great concern for Indigenous Australians across all ages. Violent alcohol‐related harms have been highlighted as a major concern. Implications: To reduce the disproportionate burden of alcohol‐related harm experienced by Indigenous Australians, targeted interventions should include the impact on families and communities and not just the individual.     

The facilitators and barriers of physical activity among Aboriginal and Torres Strait Islander regional sport participants

Background : Disparities in health perspectives between Indigenous and non‐Indigenous populations are major concerns in many of the world's well‐developed nations. Indigenous populations are largely less healthy, more prone to chronic diseases, and have an earlier overall mortality than non‐Indigenous populations. Low levels of physical activity (PA) contribute to the high levels of disease in Indigenous Australians. Method : Qualitative analysis of structured one‐on‐one interviews discussing PA in a regional setting. Participants were 12 Indigenous Australian adults, and 12 non‐Indigenous Australian adults matched on age, sex, and basketball division. Results : Most participants reported engaging in regular exercise; however, the Indigenous group reported more barriers to PA. These factors included cost, time management and environmental constraints. The physical facilitators identified by our Indigenous sample included social support, intrinsic motivation and role modelling. Conclusion : Findings describe individual and external factors that promote or constraint PA as reported by Indigenous Australian adults. Results indicate that Indigenous people face specific barriers to PA when compared to a non‐Indigenous sample. Implications for public health: This study is the first to compare the perspective of Indigenous Australians to a matched group of non‐Indigenous Australians and provides useful knowledge to develop public health programs based on culturally sensitive data.     

Stressful life events, resources, and access: key considerations in quitting smoking at an Aboriginal Medical Service

OBJECTIVE: Aboriginal and Torres Strait Islander people experience adverse health outcomes and have high rates of smoking and related illnesses. This brief report describes stress as a barrier to quitting smoking derived from reflections within an Aboriginal Medical Service and makes recommendations for intervention development. METHODS: A high-intensity smoking cessation program was conducted within a suburban Aboriginal Medical Service in Western Sydney, Australia, over a 10-month period. The intervention included weekly cessation counselling sessions and dispensation of free nicotine replacement therapy (NRT). RESULTS: During the observation period, 32 clients made quit attempts. To date, three clients (9%) have quit smoking. Chronic and intercurrent life stressors were noted to be the main barriers to smoking cessation described by participants. CONCLUSIONS: Achieving smoking cessation among Indigenous people is made significantly more complex because of multiple life stressors experienced. IMPLICATIONS: Future interventions targeting Indigenous Australians should take greater account of stressful life events and their impact on quitting smoking.     

Indigenous Australians are under-represented in longitudinal ageing studies

Objective: Evidence‐based policy depends on the availability of high‐quality research that is relevant to the population. This study aimed to identify the available data on the health of older Indigenous Australians in population‐based longitudinal studies of ageing. Approach: Evaluation of the Dynamic Analyses to Optimise Ageing Project (DYNOPTA) dataset that has pooled nine Australian longitudinal ageing studies, six of which were analysed here. Main outcome measures: Proportions of the DYNOPTA sample identified as Indigenous. Results: Indigenous participants made up 0.7% of males and 0.5% of females in the weighted sample, compared with 0.8% of both sexes in the Australian population. Indigenous under‐representation is greater at ages 45–54 than at older ages, despite overall greater participation in this age range. Conclusions and implications: Within the existing Australian longitudinal ageing studies, Indigenous Australians are under‐represented. This means there is a significant gap in the evidence base relating to the health of older Indigenous Australians. Research approaches specifically designed to address the health and wellbeing of older Indigenous Australians are urgently required.     

Systematic review to inform prevention and management of chronic disease for Indigenous Australians: overview and priorities

Objective: To describe the main characteristics of systematic reviews addressing questions of chronic disease and related risk factors for Indigenous Australians. Methods: We searched databases for systematic reviews meeting inclusion criteria. Two reviewers assessed quality and extracted characteristics using pre‐defined tools. Results: We identified 14 systematic reviews. Seven synthesised evidence about health intervention effectiveness; four addressed chronic disease or risk factor prevalence; and six conducted critical appraisal as per current best practice. Only three reported steps to align the review with standards for ethical research with Indigenous Australians and/or capture Indigenous‐specific knowledge. Most called for more high‐quality research. Conclusion: Systematic review is an under‐utilised method for gathering evidence to inform chronic disease prevention and management for Indigenous Australians. Relevance of future systematic reviews could be improved by: 1) aligning questions with community priorities as well as decision maker needs; 2) involvement of, and leadership by, Indigenous researchers with relevant cultural and contextual knowledge; iii) use of critical appraisal tools that include traditional risk of bias assessment criteria and criteria that reflect Indigenous standards of appropriate research. Implications: Systematic review method guidance, tools and reporting standards are required to ensure alignment with ethical obligations and promote rigor and relevance.     

Differences in primary health care delivery to Australia's Indigenous population: a template for use in economic evaluations

ABSTRACT: BACKGROUND: Health economics is increasingly used to inform resource allocation decision-making, however, there is comparatively little evidence relevant to minority groups. In part, this is due to lack of cost and effectiveness data specific to these groups upon which economic evaluations can be based. Consequently, resource allocation decisions often rely on mainstream evidence which may not be representative, resulting in inequitable funding decisions. This paper describes a method to overcome this deficiency for Australia's Indigenous population. A template has been developed which can adapt mainstream health intervention data to the Indigenous setting. METHODS: The 'Indigenous Health Service Delivery Template' has been constructed using mixed methods, which include literature review, stakeholder discussions and key informant interviews. The template quantifies the differences in intervention delivery between best practice primary health care for the Indigenous population via Aboriginal Community Controlled Health Services (ACCHSs), and mainstream general practitioner (GP) practices. Differences in costs and outcomes have been identified, measured and valued. This template can then be used to adapt mainstream health intervention data to allow its economic evaluation as if delivered from an ACCHS. RESULTS: The template indicates that more resources are required in the delivery of health interventions via ACCHSs, due to their comprehensive nature. As a result, the costs of such interventions are greater, however this is accompanied by greater benefits due to improved health service access. In the example case of the polypill intervention, 58% more costs were involved in delivery via ACCHSs, with 50% more benefits. Cost-effectiveness ratios were also altered accordingly. CONCLUSIONS: The Indigenous Health Service Delivery Template reveals significant differences in the way health interventions are delivered from ACCHSs compared to mainstream GP practices. It is important that these differences are included in the conduct of economic evaluations to ensure results are relevant to Indigenous Australians. Similar techniques would be generalisable to other disadvantaged minority populations. This will allow resource allocation decision-makers access to economic evidence that more accurately represents the needs and context of disadvantaged groups, which is particularly important if addressing health inequities is a stated goal.     

Closing the Gaps: competing estimates of Indigenous Australian life expectancy in the scientific literature

Objective: Closing the gap in life expectancy between Indigenous and other Australians within a generation is central to national Indigenous reform policy (Closing the Gap). Over time, various methods of estimating Indigenous life expectancy and with that, the life expectancy gap, have been adopted with differing, albeit non‐comparable results. We present data on the extent of the gap and elucidate the pattern of use and interpretations of the different estimates of the gap, between 2007 and 2012. Methods: An extensive search was conducted for all peer‐reviewed health publications citing estimates of and/or discussing the life expectancy of Indigenous Australians, for the period 2007–2012. Results: Five predominant patterns of citation of the gap estimates were identified: 20 years, 17 years, 15–20 years, 13 years, and 11.5 years for males and 9.7 years for females. Some authors misinterpret the most recent estimates as reflecting improvement from the 17‐year figure, rather than the result of different methods of estimation. Support for the direct methods used to calculate Indigenous life expectancy is indicated. Conclusions and Implications: A specific estimate of the life expectancy gap has not been established among stakeholders in Indigenous health. Agreement on the magnitude of the gap is arguably needed in order to evaluate strategies aimed at improving health outcomes for Indigenous Australians. Moreover, measuring progress towards ‘closing the gap’ depends on the availability of comparable estimates, using the same techniques of measurement to assess changes over time.     

Healthy Country: Healthy People? Exploring the health benefits of Indigenous natural resource management

OBJECTIVE: Decades of health-related research have produced a large body of knowledge describing alarming rates of morbidity, mortality and social/cultural disruption among Indigenous Australians, but have failed to deliver sustainable interventions to arrest the deepening spiral of ill-health. This paper explores the potential of Indigenous natural resource management (NRM) activities to promote and preserve Indigenous health in remote areas of northern Australia. METHOD: A literature review of the health, social science and ecology peer-reviewed journals and secondary literature. CONCLUSIONS AND IMPLICATIONS: Effective interventions in Indigenous health will require trans-disciplinary, holistic approaches that explicitly incorporate Indigenous health beliefs and engage with the social and cultural drivers of health. Aboriginal peoples maintain a strong belief that continued association with and caring for ancestral lands is a key determinant of health. Individual engagement with 'country' provides opportunities for physical activity and improved diet as well as boosting individual autonomy and self-esteem. Internationally, such culturally congruent health promotion activities have been successful in programs targeting substance abuse and chronic diseases. NRM is fundamental to the maintenance of biodiversity of northern Australia. Increased support for Indigenous involvement in land and sea NRM programs would also deliver concrete social benefits for communities including opportunities for sustainable and culturally apt regional employment, applied education and economic development. NRM may also reinvigorate societal/cultural constructs, increasing collective esteem and social cohesion.     

Health Promotion and the Preventative Health Taskforce

The release in October of the Preventative Health Taskforce's discussion paper, ‘Australia: the healthiest country by 2020’ offers health promotion practitioners their greatest opportunity to participate in national policy development for many years. The Taskforce, which was established by the Federal Health Minister Nicola Roxon in March, has been asked to develop a National Preventative Health Strategy for the Government by mid‐2009, focusing initially on obesity, smoking and alcohol. The Taskforce has proposed the following targets to be achieved by 2020:

• halt and reverse the rise in overweight and obesity;
• reduce the prevalence of daily smoking to 9% or less;
• reduce the prevalence of harmful drinking for all Australians by 30%; and
• contribute to the ‘Close the Gap’ target for Indigenous people, reducing the 17‐year life expectancy gap between Indigenous and non‐Indigenous Australians.