Indigenous health programs require more than just good ideas

[Extract] Despite efforts to close the gap, Indigenous Australians continue to suffer two-and-a-half times the burden of disease than the total Australian population, with most of the health gap caused by preventable chronic diseases. Clearly, strengthening the capacity of the health system to deliver effective and responsive health services is a critical priority. But improving Indigenous health requires more than resources and good intentions; how the programs are implemented, evaluated and translated is equally important. The Family Wellbeing program was developed by Indigenous people, for Indigenous people, and has great relevance and credibility in Indigenous health program delivery. It also offers important lessons on program implementation, evaluation and translation

Cultural competency in the delivery of health services for Indigenous people

Aim and objectives This review aims to examine available evidence on cultural competence in health care settings to identify key approaches and strategies that can contribute to improving the development and implementation of Indigenous health services and programs. The objectives are to: 1. define cultural competency –– we consider the significance of cultural competence and how it has been defined in international and local literature, including the use of similar terms and meanings 2. report on the quantity, nature and quality of available evidence –– we look at available evidence on cultural competency in Australia, New Zealand, Canada and the United States, including how cultural competence has been measured, and assess the quality of the evidence against basic methodological criteria 3. identify approaches and strategies that are effective in improving cultural competency among health services staff 4. examine the relationship between cultural competency and health outcomes 5. develop an evidence-informed conceptual framework of cultural competency

Improving Indigenous Australian governance: the how and what of capacity strengthening

In this paper, capacity strengthening will be pragmatically explored in response to two key questions: what enabling approaches are accessible for Aboriginal and Torres Strait Islander Australian (hereafter Indigenous) organisations to effectively make governance decisions; and what approaches can facilitate partnership processes between communities and governments for improving Indigenous Australian organisational governance. In particular, it will consider 1) the need to strengthen both hard capacities such as resources, technical skills, functions, structures, equipment and so forth; and soft capacities such as values, morale, engagement, motivation, incentives and staff wellbeing; and 2) one strategy that has successfully been used to facilitate partnership between Indigenous organisations and governments - reflective participatory approaches. It will draw from reflective short case study examples in which the authors have participated to demonstrate how, where and when capacity strengthening principles have been adopted. Given the paucity of well-designed evaluations, key principles and practices that appear to work to strengthen capacity will be discussed. Key amongst these are community ownership of governance improvement, collaborative development approaches that are context-dependent and long-term partnerships between government agencies and Indigenous communities built on trust and respect. Capacity-strengthening must have a clear notion of what type of capacity is being strengthened, for whom, and how the effectiveness will be measured

The implementation and evaluation health promotion services and programs to improve cultural competency: a systematic scoping review

Background: Cultural competency is a multifaceted intervention approach which needs to be implemented at various levels of healthcare systems to improve quality of care for culturally and ethnically diverse populations. One level of healthcare where cultural competency is required is in the provision of health promotion services and programs targeted to diverse patient groups who experience healthcare and health inequalities. To inform the implementation and evaluation of health promotion programs and services to improve cultural competency, research must assess both intervention strategies and intervention outcomes. Methods: This scoping review was completed as part of a larger systematic literature search conducted on evaluations of cultural competence interventions in health care in Canada, the United States, Australia and New Zealand. Seventeen peer-reviewed databases, 13 websites and clearinghouses, and 11 literature reviews were searched. Overall, 64 studies on cultural competency interventions were found, with 22 being health promotion programs and services. A process of thematic analysis was utilized to identify key intervention strategies and outcomes reported in the literature. Results: The review identified three overarching strategies utilised in health promotion services and programs to improve cultural competency: community focused strategies, culturally focused strategies, and language focused strategies. Studies took different approaches to delivering culturally competent health interventions; with the majority incorporating multiple strategies from each overarching category. There were various intermediate healthcare and health outcomes reported across the included studies. Most commonly reported were positive reports of patient satisfaction, patient/participant service access and program/study retention rates. The health outcome results indicate positive potential of health promotion services and programs to improve cultural competency to impact cardiovascular disease and mental health outcomes. However, due to measurement and study quality issues, it is difficult to determine the extent of the impacts. Discussion: Examined together, these intervention strategies and outcomes provide a framework which can be used by service providers and researchers in the implementation and evaluation of health promotion services and programs to improve cultural competency. While there is evidence indicating the effectiveness of such health promotion interventions in improving intermediate and health outcomes, further attention is needed to issues of measurement and study quality

Evaluating and Measuring Aboriginal and Torres Strait Islander Maternal and Infant Health Programs: a literature review for the Apunipima Baby Basket evaluation

The underutilisation of maternal and infant health (MIH) care services by Aboriginal and Torres Strait Islander women, along with the lack of appropriate, culturally safe care, has been a driving factor behind creating Aboriginal and Torres Strait Islander MIH care programs such as the Baby Basket (BB) program. High quality evaluations of MIH programs are necessary for quality, evidence-based care. This literature review has been conducted to inform the evaluation design and ongoing quality improvement of the BB program. The review summarises previously used evaluation designs and available indicators for evaluating and monitoring Aboriginal and Torres Strait Islander MIH programs. An outline of the issues associated with these types of evaluation designs and indicators is provided, along with suggestions for improving data collection and evaluation quality

Aboriginal and Torres Strait Islander maternal and child health and wellbeing: a systematic search of programs and services in Australian primary health care settings

Background: Persistent disparities in pregnancy and birth outcomes between Aboriginal and Torres Strait Islander and other Australians evidence a need to prioritise responsive practice in Maternal Child Health (MCH). This study reviewed the existing knowledge output on Aboriginal and Torres Strait Islander MCH programs and services with the objective to advance understanding of the current evidence base and inform MCH service development, including the identification of new research priorities. Methods: A systematic search of the electronic databases Informit, Proquest, PubMed, Scopus, Wiley, and Cinahl, and 9 relevant websites was undertaken for the period 1993-2012. The reference lists of MCH program reviews were hand-searched for additional relevant studies which met the eligibility criteria. The study designs of included publications were classified and the characteristics extracted and categorized. Evaluation quality was assessed using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool for Quantitative Studies and the Critical Appraisal Skills Program (CASP) tool for qualitative studies. Results: Twenty-three search results were identified for inclusion, with the majority published in 2003-2012. Fifty two percent of publications reported on programs and services operating out of Aboriginal Community Controlled Health Organisations, with antenatal and postnatal care the main intervention type/s, and health promotion/education and advice/support the most common intervention component. Outcomes such as increased antenatal attendance and higher infant birth weights were reported in some intervention studies, however methodological quality varied considerably with quantitative studies typically rated weak. Conclusion: The prevalence of community controlled and/or community-based programs is significant given the health and wellbeing implications of self-determination. While the literature highlights the promise of many intervention models and program components used there are some significant gaps in the documentation and implementation of important MCH interventions. Similarly, while positive health outcomes were reported there are issues with key measures used and study quality. This review highlights the need to improve the quality of evaluations of MCH programs for Aboriginal and Torres Strait Islander women and to address the key evidence gaps in responding to their health and wellbeing needs

Staff Capacity Development Initiatives That Support the Well-being of Indigenous Children in Their Transitions to Boarding Schools: A Systematic Scoping Review

Background: Secondary education for Indigenous children from remote communities requires separation from their communities and families. As these students transition to boarding schools, they face several challenges that are additional to those faced by their non-Indigenous peers. In response, adequate academic and emotional well-being support needs to be provided by school and residential staff. This systematic review reports on international and Australian capacity development initiatives for education and boarding staff that support these students. \ud Methods: Five databases were searched using database-specific search strings, considering peer-reviewed articles and gray literature, published between 2001 and 2016. The resultant publications were screened to identify (a) their nature and quality and (b) their characteristics in terms of aims, strategies, and outputs. \ud Results: Seven hundred thirty-six citations were identified; 51 full text publications met inclusion criteria for assessment. Seven publications were eligible for review. Staff capacity building initiatives encompassed a range of approaches, including training, feedback, reflective practice, mentoring, networking, and supervision. Only one publication focused specifically on the support of education staff, others were centred on improving educational, behavioral, and emotional outcomes for Indigenous boarding school students. All of the research was descriptive, with only two original research publications. \ud Conclusion: Despite a variety of approaches being described in brief, we found no high quality research that focused exclusively on staff capacity building approaches in the Indigenous boarding school context. The few publications available to review were exclusively descriptive in nature, highlighting a clear need for well-executed evaluation research

"It's all about relationships": the place of boarding schools in promoting and managing health and wellbeing of Aboriginal and Torres Strait Islander secondary school students

Introduction: In recent years, Australian government policies have promoted access to secondary education through boarding schools for Aboriginal and Torres Strait Islander (hereafter respectfully termed Indigenous) students from remote communities. These students experience the poorest health of any Australian adolescent group. This exploratory study examines how boarding schools across Queensland promote and manage healthcare and wellbeing support for Indigenous students. Methods: Qualitative grounded theory methods were used to sample and collect data from the healthcare and wellbeing support staff of eight Queensland boarding schools using semi-structured interviews. Data were coded using NVIVO software and compared to identify the context, conditions, core process, strategies and outcomes of boarding schools' healthcare and wellbeing support. Preliminary findings were fed back to school staff and students' family members for discussion and response at an annual Schools and Communities meeting. Results: Boarding school health staff support Indigenous student-centred healthcare and wellbeing by weaving a relational network with students, families, school staff and external healthcare providers. Either through on-site or school-linked centres, they provide students with access to healthcare services, support wellbeing, and offer health education. Through these strategies, they enable students' participation in education and learning, receive quality healthcare improvement, "move to a better head space", and become responsible for their own healthcare. Enabling conditions are the professional and cultural capabilities of school staff, school leadership and commitment, compatibility of intersectoral systems and resourcing of healthcare and wellbeing support. Conclusions: Boarding schools are doing considerable work to improve the promotion and management of healthcare and wellbeing support for Indigenous students, but there is considerable variation across schools, impacts are not formally monitored or reported, and there are many opportunities for improvement. Working towards a best practice framework, school staff identified a need for a multi-levelled relational model of healthcare and wellbeing support to be iteratively embedded at each stage of the school cycle: at intake; enrolment; term one; and throughout the school year (including in emergencies/crises)

Towards best practice during COVID-19: A responsive and relational program with remote schools to enhance the wellbeing of Aboriginal and Torres Strait Islander students

Purpose: From 2018, the Schools Up North (SUN) programme worked with three remote Australian schools to enhance their capability and resilience to support the wellbeing and mental health of Aboriginal and Torres Strait Islander students and staff. This paper explores the implementation of SUN during the first two years of COVID-19 (2020–2021). Method: Using grounded theory methods, school staff, other service providers and SUN facilitators were interviewed, with transcripts and programme documents coded and interrelationships between codes identified. An implementation model was developed. Results: The SUN approach was place-based, locally informed and relational, fostering school resilience through staff reflection on and response to emerging contextual challenges. Challenges were the: community lockdowns and school closures; (un)availability of other services; community uncertainty and anxiety; school staff capability and wellbeing; and risk of educational slippage. SUN strategies were: enhancing teachers’ capabilities and resources, facilitating public health discussions, and advocating at regional level. Outcomes were: enhanced capability of school staff; greater school-community engagement; student belonging and engagement; a voice for advocacy; and continuity of SUN's momentum. Conclusions: The resilience approach (rather than specific strategies) was critical for building schools’ capabilities for promoting students and staff wellbeing and provides an exemplar for remote schools globally

Apunipima baby basket program: a retrospective cost study

Background: The Baby Basket initiative was developed by Apunipima Cape York Health Council (ACYHC) to address poor maternal and child health (MCH) in Cape York, the northernmost region of Queensland. While positive outcomes for Indigenous MCH programs are reported in the literature, few studies have a strong evidence base or employ a sound methodological approach to evaluation. The aim of the cost study is to identify the resources required to deliver the Baby Basket program in the remote communities of Cape York. It represents an initial step in the economic evaluation of the Apunipima Baby Basket program. The aim of this study was to report whether the current program represents an effective use of scarce resources. Method: The cost study was conducted from the perspective of the health providers and reflects the direct resources required to deliver the Baby Basket program to 170 women across 11 communities represented by ACYHC. A flow diagram informed by interviews with ACYHC staff, administrative documents and survey feedback was used to map the program pathway and measure resource use. Monetary values, in 2013 Australian dollars, were applied to the resources used to deliver the Baby Basket program for one year. Results: The total cost of delivering the Baby Basket progam to 170 participants in Cape York was $148,642 or approximately,$874 per participant. The analysis allowed for the cost of providing the Baby Baskets to remote locations and the time for health workers to engage with women and thereby encourage a relationship with the health service. Routinely collected data showed improved engagement between expectant women and the health service during the life of the program. Conclusion: The Apunipima Baby Basket cost study identifies the resources required to deliver this program in remote communities of Cape York and provides a framework that will support prospective data collection of more specific outcome data, for future cost-effectiveness analyses and cost-benefit analyses. An investment of $874 per Baby Basket participant was associated with improved engagement with the health service, an important factor in maternal and child health