Process evaluation of a primary healthcare validation study of a culturally adapted depression screening tool for use by Aboriginal and Torres Strait Islander people: study protocol

Process evaluations are conducted alongside research projects to identify the context, impact and consequences of research, determine whether it was conducted per protocol and to understand how, why and for whom an intervention is effective. We present a process evaluation protocol for the Getting it Right research project, which aims to determine validity of a culturally adapted depression screening tool for use by Aboriginal and Torres Strait Islander people. In this process evaluation, we aim to: (1) explore the context, impact and consequences of conducting Getting It Right, (2) explore primary healthcare staff and community representatives' experiences with the research project, (3) determine if it was conducted per protocol and (4) explore experiences with the depression screening tool, including perceptions about how it could be implemented into practice (if found to be valid). We also describe the partnerships established to conduct this process evaluation and how the national Values and Ethics: Guidelines for Ethical Conduct in Aboriginal and Torres Strait Islander Health Research is met. Realist and grounded theory approaches are used. Qualitative data include semistructured interviews with primary healthcare staff and community representatives involved with Getting it Right. Iterative data collection and analysis will inform a coding framework. Interviews will continue until saturation of themes is reached, or all participants are considered. Data will be triangulated against administrative data and patient feedback. An Aboriginal and Torres Strait Islander Advisory Group guides this research. Researchers will be blinded from validation data outcomes for as long as is feasible. The University of Sydney Human Research Ethics Committee, Aboriginal Health and Medical Research Council of New South Wales and six state ethics committees have approved this research. Findings will be submitted to academic journals and presented at conferences. ACTRN12614000705684. [Abstract copyright: © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Career Pathways for the Aboriginal and Torres Strait Islander Health Workforce: Literature Review Report: Career Pathways Project

This literature review has been undertaken as a part of the research activities for the Career Pathways Project (CPP) for Aboriginal and Torres Strait Islander health professionals commissioned by the Lowitja Institute. The CPP is focussed on providing insights and guidance to enhance the capacity of the health system to retain and support the development and careers of Aboriginal and Torres Strait Islander people in the health workforce and takes a national perspective. This project was initiated by Aboriginal Community Controlled Organisations (ACCHOs) and involves leadership at all levels by Aboriginal and Torres Strait Islander investigators, partners and field researchers. The aim of the literature review is to examine the peer and grey literature to inform the broader CPP research activities and proposed actions for strengthening the career development opportunities and pathways of Aboriginal and Torres Strait Islander people in the health workforce. The review focuses on four key questions: 1. What are the unique skill sets and values that Aboriginal and Torres Strait Islander health staff and health professionals can, and do, contribute to health services? 2. What are the experiences of Aboriginal and Torres Strait Islander health staff and health professionals in entering, and progressing, their careers within health services? 3. What factors facilitate Aboriginal and Torres Strait Islander health workforce career development and career advancement? 4. What factors impede Aboriginal and Torres Strait Islander health workforce career development and career advancement? In undertaking this literature review and addressing these questions, we first briefly provide a snapshot of the Aboriginal and Torres Strait Islander health workforce and then consider key concepts related to careers. We do so to frame the findings of the literature review provided within the main body of this report and to acknowledge the importance of privileging the contexts, values and perspectives of those who constitute the Aboriginal and Torres Strait Islander health workforce

An Australian national survey of First Nations careers in health services

A strong First Nations health workforce is necessary to meet community needs, health rights, and health equity. This paper reports the findings from a national survey of Australia’s First Nations people employed in health services to identify enablers and barriers to career development, including variations by geographic location and organisation type. A cross-sectional online survey was undertaken across professions, roles, and jurisdictions. The survey was developed collaboratively by Aboriginal and non Aboriginal academics and Aboriginal leaders. To recruit participants, the survey was promoted by key professional organisations, First Nations peak bodies and affiliates, and national forums. In addition to descriptive statistics, logistic regression was used to identify predictors of satisfaction with career development and whether this varied by geographic location or organisation type. Of the 332 participants currently employed in health services, 50% worked in regional and remote areas and 15% in Aboriginal Community-Controlled Health Organisations (ACCHOs) with the remainder in government and private health services. All enablers identified were associated with satisfaction with career development and did not vary by location or organisation type. “Racism from colleagues” and “lack of cultural awareness,” “not feeling supported by their manager,” “not having role models or mentors,” and “inflexible human resource policies” predicted lower satisfaction with career development only for those employed in government/other services. First Nations people leading career development were strongly supported. The implications for all workplaces are that offering even a few career development opportunities, together with supporting leadership by Aboriginal and Torres Strait Islander staff, can make a major difference to satisfaction and retention. Concurrently, attention should be given to building managerial cultural capabilities and skills in supporting First Nations’ staff career development, building cultural safety, providing formal mentors and addressing discriminatory and inflexible human resources policies

'We're here to listen and help them as well': a qualitative study of staff and Indigenous patient perceptions about participating in social and emotional wellbeing research at primary healthcare services

Research can inform culturally-appropriate care to strengthen social and emotional wellbeing (SEWB) among Aboriginal and Torres Strait Islander (hereafter, the term 'Indigenous Peoples' is respectfully used and refers to all Aboriginal and/or Torres Strait Islander Peoples of Australia). We acknowledge the cultural diversity of Australia's Indigenous First Peoples and they do not represent a homogenous group.) (hereafter Indigenous) Peoples. We explore the perspectives of primary healthcare staff and Indigenous patients about their willingness to and experiences participating in SEWB research. Process evaluation using grounded theory approaches of Getting it Right: The validation study, a national validation designed Indigenous SEWB research project (N = 500). Primary healthcare staff (n = 36) and community members (n = 4) from nine of ten primary healthcare services involved with the research project completed qualitative semi-structured interviews. Interview data were triangulated with participant feedback (responses to structured questions and free-text feedback collected during Getting it Right), study administrative data (participant screening logs, communication logs, study protocol, deviation logs and ethics correspondence) and interviewer field notes. Three themes about staff, patient and community perspectives concerning research participation developed: (1) considering the needs, risk, preferences and impact of participation in research for staff, patients and community; (2) building staff confidence speaking to patients about research and SEWB problems and (3) patients speaking openly about their SEWB. Some staff described pressure to ensure patients had a positive experience with the research, to respond appropriately if patients became upset or SEWB problems were identified during interviews, or due to their dual role as community member and researcher. Patients and staff reported that patients were more likely to participate if they knew the staff outside of the service, especially staff with a shared cultural background, and they perceived SEWB as a community priority. Staff reported their skills speaking to patients about the research and SEWB improved during the research, which built their confidence. Contrary to staff preconceptions, staff and patients reported that many patients appreciated the opportunity to speak about their SEWB and contributing to research that may eventually enhance SEWB in their community. Our research project was considered acceptable by most staff and patients. The positive outcomes reported by staff and feedback from patients highlights the importance of providing opportunities for people to speak about their SEWB and for research-informed SEWB PHC care. Getting it Right is registered on ANZCTR12614000705684

Process evaluation of the Getting it Right study and acceptability and feasibility of screening for depression with the aPHQ-9

The Getting it Right study determined the validity, sensitivity, specificity and acceptability of the culturally adapted 9-item Patient Health Questionnaire (aPHQ-9) as a screening tool for depression in Aboriginal and Torres Strait Islander (hereafter referred to as Indigenous) people. In this process evaluation we aimed to explore staff perceptions about whether Getting it Right was conducted per protocol, and if the aPHQ-9 was considered an acceptable and feasible screening tool for depression in primary healthcare. This process evaluation will provide information for clinicians and policy makers about the experiences of staff and patients with Getting it Right and what they thought about using the aPHQ-9. Process evaluation using grounded theory approaches. Semi-structured interviews with primary healthcare staff from services participating in Getting it Right were triangulated with feedback (free-text and elicited) from participants collected during the validation study and field notes. Data were thematically analysed according to the Getting it Right study protocol to identify the acceptability and feasibility of the aPHQ-9. Primary healthcare staff (n = 36) and community members (n = 4) from nine of the ten participating Getting it Right services and Indigenous participants (n = 500) from the ten services that took part. Most staff reported that the research was conducted according to the study protocol. Staff from two services reported sometimes recruiting opportunistically (rather than recruiting consecutive patients attending the service as outlined in the main study protocol), when they spoke to patients who they knew from previous interactions, because they perceived their previous relationship may increase the likelihood of patients participating. All Getting it Right participants responded to at least six of the seven feedback questions and 20% provided free-text feedback. Most staff said they would use the aPHQ-9 and most participants said that the questions were easy to understand (87%), the response categories made sense (89%) and that they felt comfortable answering the questions (91%). Getting it Right was predominantly conducted according to the study protocol. The aPHQ-9, the first culturally adapted, nationally validated, freely available depression screening tool for use by Indigenous people, appears to be acceptable and feasible to use. Australian New Zealand Clinical Trial Registry ANZCTR12614000705684 , 03/07/2014

Career Pathways for the Aboriginal and Torres Strait Islander Health Workforce: Secondary Data Workforce Report: Career Pathways Project

Data sets and data collection: The method for this component of the broader mixed methods study of Aboriginal and Torres Strait Islander Career Pathways consists exclusively of undertaking descriptive statistical analysis of existing data. The limitations of using secondary data sources, particularly when unit record data is not available for re-analysis, are acknowledged. Accordingly, specific inferences from the findings are limited, and the findings ultimately need to be considered in conjunction with the findings from other study components. Five main sources of data were explored as follows: • ABS Population Census data interrogated by Aboriginality, age, gender, occupational classification, industry classification and educational level • Department of Employment, Education and Workplace Relations (DEEWR) data was used to provide an insight into the age and gender composition of the current Aboriginal and Torres Strait Islander student population and future entrants to health professions • Data from the National Centre for Vocational Education Research (NCVER) includes relevant course enrolments and course outcomes (graduations) from VET level courses • The Commonwealth Department of Health (Workforce Branch) holds data on of all the processed annual workforce surveys of registered professions • Australian Institute of Health and Welfare (AIHW) holds data from an annual survey of Aboriginal community-controlled services receiving Commonwealth funding to deliver primary health care and other services. They are required to contribute to the Online Services Report (OSR) annually. Current situation: In the last twenty years there has been impressive growth in the absolute number of Aboriginal and Torres Strait Islander people in the health workforce. The growth rates average 4.7% per annum. These are much higher workforce growth rates than the total general workforce population. Whilst only accounting for approximately 20% of the total Aboriginal and Torres Strait Islander health workforce, employment growth in ACCHSs for the last 10 years (AIHW, 2017a) has contributed significantly to total growth. Despite the significant growth in the Aboriginal and Torres Strait Islander workforce, this analysis has revealed that there has been no real improvement in the Aboriginal and Torres Strait Islander proportion of the total health workforce (and especially as yet the health professional workforce). Of thirty five health occupations reviewed, only six occupations had an Aboriginal and Torres Strait Islander workforce proportion of the total workforce that was equal to or greater than 3% (equivalent with the total population proportion). Equally discouraging has been a lack of change in the proportion of Aboriginal and Torres Strait Islander workforce to the Aboriginal and Torres Strait Islander population. lack of change in the proportional representation of Aboriginal and Torres Strait Islanders in the total health workforce appears to be primarily due to an equally rapid growth in the non-Indigenous health workforce. The lack of change in the proportion of Aboriginal and Torres Strait Islander workforce per the Aboriginal and Torres Strait Islander population is attributed to a significant increase in the number of persons identifying as Aboriginal and Torres Strait Islander, against which Aboriginal and Torres Strait Islander health worker participation has only just kept pace. Factors facilitating career development and advancement: There has been significant growth in enrolments in, and graduations from, health-related higher education and tertiary education courses. This growth in education activity has clearly helped fuel workforce growth in general, but particularly in certain health professions where the initial base number was very low (e.g. pharmacists, physiotherapists and medical imaging professionals). The overall increases in the participation of Aboriginal and Torres Strait Islander workers in the health sector is helping potentially to create a “critical mass effect”. This effect will assist in reducing the influence of culturally unsafe workplaces acting as a barrier to future aspirants wanting to enter health professions. The presence of greater numbers of Aboriginal and Torres Strait Islander workers in particular professions also provides a larger pool of appropriate mentors and career coaches to help newer entrants survive and prosper. Policies and practices to nurture and optimise the value from these professional critical mass populations (through structured mentor programs, appropriate training and remuneration) will be important. Factors impeding career development and advancement? A disproportionate amount of recent Aboriginal and Torres Strait Islander workforce growth has been in low status and lower paying jobs (such as personal care workers). These jobs tend to have ‘shorter’ salary scale structures that terminate at comparatively low-end points with poor articulation to other roles particularly roles in professional careers. The preponderance of Aboriginal and Torres Strait Islander workforce growth in occupations with poorer career progress prospects is strongly influenced by what sectors of the health industry in which employment is occurring. More employment growth has happened in residential care, personal care and some primary health care industry sectors where there are limited career progression opportunities, as opposed to employment in the hospital sector where career pathways, because of greater workforce sizes and more hierarchical organization structures, tend to be longer and provide greater career progression opportunities. The workforce in these jobs nevertheless represents a potential population to be rapidly developed to assume health professional careers. They have existing health work competencies and health industry understanding and can have significant motivation to progress. Policies and practices to realise the potential of this population require going beyond local initiatives and require structures that cross individual organization boundaries to provide quality practice supervision, career coaching and access to education that is more than study leave. Other influences Opportunities for employment of Aboriginal and Torres Strait Islanders in the health workforce seems to vary by jurisdiction (some States have better employment outcomes), by the profession / occupation (several health professions seem to be doing better than most others), by sector in which employed (the Aboriginal Community Controlled sector is a greater employer of Aboriginal and Torres Strait Islanders compared with the Government or private sectors) and by location of employment (which compared to the non-Indigenous workforce favours rural and remote settings). These influences can be both positive or negative to career progress of Aboriginal and Torres Strait Islanders in the health workforce

We Are working for our People: Growing and Strengthening the Aboriginal and Torres Strait Islander Health Workforce: Career Pathways Project Report

Expanding and strengthening the Aboriginal and Torres Strait Islander health professional workforce is recognised as crucial for improving the health and wellbeing of Aboriginal and Torres Strait Islander communities. The Career Pathways Project took a national perspective and aimed to provide insights and guidance to enhance the capacity of the health system to retain and support the development and careers of Aboriginal and Torres Strait Islander people in the health workforce. The research incorporated a mixed-methods design, gathering and synthesising qualitative and quantitative data from primary and secondary sources. The main research activities included a literature review, national stakeholder consultations and a survey of the workforce, secondary data analysis, individual career trajectory interviews, locally situated case studies (focus groups and interviews) and data synthesis. The Aboriginal and Torres Strait Islander health workforce is made up of individuals who are passionate about what they do and motivated by a commitment to improve the wellbeing and health of their communities. To fulfil this commitment, they are willing to embark on a lifelong journey of learning to address the issues they see facing their families and broader communities, even if this involves significant challenges, changes in career goals, isolation or working in a health system that is not always flexible or responsive to community needs. Aboriginal and Torres Strait Islander health professionals’ unique skill set, which comes from their lived cultural experiences and ways of being and doing, makes them powerful advocates and agents of change to improve health outcomes. A holistic model of health works for Aboriginal and Torres Strait Islander people and communities. The community-controlled sector works from a platform of respect and connection within comprehensive primary healthcare, which promotes a holistic approach and integrates the cultural and social determinants of health into the planning and delivery of health services. This model acknowledges and engages with community structures, allowing culture to guide service delivery strategies and enabling innovative approaches to care, and includes the participation of consumers, their families and broader communities in defining their healthcare needs. All sectors can benefit by considering this model of care in order to improve the health and wellbeing of their Aboriginal and Torres Strait Islander consumers and local communities, and their Indigenous health workforce. The Aboriginal and Torres Strait Islander health workforce delivers a holistic model of care services that is culturally informed and has its own networks and complexities. Without the dedication of the local Aboriginal and Torres Strait Islander health workforce in remote communities, it would be impossible to deliver effective local health promotion and healthcare services that reinforce positive community attitudes to health. Jobs and careers are restricted by funding strategies that constrain the types of services and employment contracts that can be offered and do not reflect local needs or collective decision-making processes. The Aboriginal and Torres Strait Islander health workforce brings an intuitive understanding of cultural safety and competence to an organisation. This understanding is often structurally embedded in the community-controlled sector’s way of operating but is not always reflected in the operational approach across all organisations in the health sector, where Aboriginal and Torres Strait Islander workers experience racism and often do not have the support of other Aboriginal and Torres Strait Islander peers and colleagues, or influence over management of services to Aboriginal and Torres Strait Islander consumers. In terms of career development, encouragement and support makes all the difference. Training and further studies may be stalled for Aboriginal and Torres Strait Islander health workforce members by organisational constraints and personal financial circumstances. Community ties to location or the absence of family support can make it difficult for individuals to participate in educational and professional development activities, such as university work placements and internships. The Aboriginal and Torres Strait Islander health workforce is boosted by individuals’ early experiences of the health system and the presence of role models and mentors, both in the community and in the workplace. Opportunities to enter the health workforce at a junior level or as a paid trainee are very influential. These experiences form the building blocks upon which further supported career progression can be built. Mentoring by respected managers and senior health professionals assists individuals to build their careers and helps the workforce as a whole to grow. The value that Aboriginal and Torres Strait Islander Health Workers bring to their positions is not reflected in some industrial awards. Lack of structured career pathways means that they are often restricted to low-paid roles in the health and community sectors, despite having multiple Vocational Education and Training (VET) and/or university qualifications. On the basis of these findings, the research team identified five contributing factors – or pillars of action – for successful careers. The pillars are: Leadership and self-determination, Cultural safety, Valuing cultural strengths, Investment in the workforce and workplace, and Education and training. General and specific strategies are suggested within each pillar. Many strategies are multifaceted and multilayered, require the engagement of one or more capacity-building pillars, and involve one or more key groups. These groups include workers, communities (such as families or health service organisations), peak community and professional organisations, training and education providers, and health systems (including funding bodies). Collaboration and partnership between jurisdictions, sectors, professional groups and communities is essential to retain, support and develop Aboriginal and Torres Strait Islander careers in the health workforce