Family-centred interventions for Indigenous early childhood well-being by primary healthcare services.

BACKGROUND: Primary healthcare, particularly Indigenous-led services, are well placed to deliver services that reflect the needs of Indigenous children and their families. Important characteristics identified by families for primary health care include services that support families, accommodate sociocultural needs, recognise extended family child-rearing practices, and Indigenous ways of knowing and doing business. Indigenous family-centred care interventions have been developed and implemented within primary healthcare services to plan, implement, and support the care of children, immediate and extended family and the home environment. The delivery of family-centred interventions can be through environmental, communication, educational, counselling, and family support approaches. OBJECTIVES: To evaluate the benefits and harms of family-centred interventions delivered by primary healthcare services in Canada, Australia, New Zealand, and the USA on a range of physical, psychosocial, and behavioural outcomes of Indigenous children (aged from conception to less than five years), parents, and families. SEARCH METHODS: We used standard, extensive Cochrane search methods. The latest search date was 22 September 2021. SELECTION CRITERIA: We included randomised controlled trials (RCTs), cluster RCTs, quasi-RCTs, controlled before-after studies, and interrupted time series of family-centred care interventions that included Indigenous children aged less than five years from Canada, Australia, New Zealand, and the USA. Interventions were included if they met the assessment criteria for family-centred interventions and were delivered in primary health care. Comparison interventions could include usual maternal and child health care or one form of family-centred intervention versus another. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were 1. overall health and well-being, 2. psychological health and emotional behaviour of children, 3. physical health and developmental health outcomes of children, 4. family health-enhancing lifestyle or behaviour outcomes, 5. psychological health of parent/carer. 6. adverse events or harms. Our secondary outcomes were 7. parenting knowledge and awareness, 8. family evaluation of care, 9. service access and utilisation, 10. family-centredness of consultation processes, and 11. economic costs and outcomes associated with the interventions. We used GRADE to assess the certainty of the evidence for our primary outcomes. MAIN RESULTS: We included nine RCTs and two cluster-RCTs that investigated the effect of family-centred care interventions delivered by primary healthcare services for Indigenous early child well-being. There were 1270 mother-child dyads and 1924 children aged less than five years recruited. Seven studies were from the USA, two from New Zealand, one from Canada, and one delivered in both Australia and New Zealand. The focus of interventions varied and included three studies focused on early childhood caries; three on childhood obesity; two on child behavioural problems; and one each on negative parenting patterns, child acute respiratory illness, and sudden unexpected death in infancy. Family-centred education was the most common type of intervention delivered. Three studies compared family-centred care to usual care and seven studies provided some 'minimal' intervention to families such as education in the form of pamphlets or newsletters. One study provided a minimal intervention during the child's first 24 months and then the family-centred care intervention for one year. No studies had low or unclear risk of bias across all domains. All studies had a high risk of bias for the blinding of participants and personnel domain. Family-centred care may improve overall health and well-being of Indigenous children and their families, but the evidence was very uncertain. The pooled effect estimate from 11 studies suggests that family-centred care improved the overall health and well-being of Indigenous children and their families compared no family-centred care (standardised mean difference (SMD) 0.14, 95% confidence interval (CI) 0.03 to 0.24; 2386 participants). We are very uncertain whether family-centred care compared to no family-centred care improves the psychological health and emotional behaviour of children as measured by the Infant Toddler Social Emotional Assessment (ITSEA) (Competence domain) (mean difference (MD) 0.04, 95% CI -0.03 to 0.11; 2 studies, 384 participants). We assessed the evidence as being very uncertain about the effect of family-centred care on physical health and developmental health outcomes of children. Pooled data from eight trials on physical health and developmental outcomes found there was little to no difference between the intervention and the control groups (SMD 0.13, 95% CI -0.00 to 0.26; 1961 participants). The evidence is also very unclear whether family-centred care improved family-enhancing lifestyle and behaviours outcomes. Nine studies measured family health-enhancing lifestyle and behaviours and pooled analysis found there was little to no difference between groups (SMD 0.16, 95% CI -0.06 to 0.39; 1969 participants; very low-certainty evidence). There was very low-certainty evidence of little to no difference for the psychological health of parents and carers when they participated in family-centred care compared to any control group (SMD 0.10, 95% CI -0.03 to 0.22; 5 studies, 975 parents/carers). Two studies stated that there were no adverse events as a result of the intervention. No additional data were provided. No studies reported from the health service providers perspective or on outcomes for family's evaluation of care or family-centredness of consultation processes. AUTHORS' CONCLUSIONS: There is some evidence to suggest that family-centred care delivered by primary healthcare services improves the overall health and well-being of Indigenous children, parents, and families. However, due to lack of data, there was not enough evidence to determine whether specific outcomes such as child health and development improved as a result of family-centred interventions. Seven of the 11 studies delivered family-centred education interventions. Seven studies were from the USA and centred on two particular trials, the 'Healthy Children, Strong Families' and 'Family Spirit' trials. As the evidence is very low certainty for all outcomes, further high-quality trials are needed to provide robust evidence for the use of family-centred care interventions for Indigenous children aged less than five years.

Network evaluation of an innovation platform in continuous quality improvement in Australian Indigenous primary healthcare.

BACKGROUND: From 2014 to 2019, the Centre for Research Excellence in Integrated Quality Improvement (CRE-IQI) was evaluated as an innovation platform focusing on continuous quality improvement in Indigenous Australian primary healthcare. Although social network analysis (SNA) is a recognized method for evaluating the functioning, collaboration and effectiveness of innovation platforms, applied research is limited. This study applies SNA to evaluate the CRE-IQI's functioning as an innovation platform. METHODS: Two surveys (2017, 2019) were conducted using social survey and network methods. Survey items covered respondent characteristics, their perceptions of the CRE-IQI's performance, and its impact and sociometric relationships. Members' relationship information was captured for the CRE-IQI at three time points, namely start (retrospectively), midpoint and final year, on three network types (knew, shared information, collaborated). SNA software was used to compute standard network metrics including diameter, density and centrality, and to develop visualizations. Survey and network results were addressed in a workshop held by members to develop improvement strategies. RESULTS: The response rate was 80% in 2017 and 65% in 2019 (n = 49 and 47, respectively). Between 2017 and 2019, respondents' mean ratings of the CRE-IQI's functioning and achievements in meeting its goals were sustained. They perceived the CRE-IQI as multidisciplinary, having effective management and governance, and incorporating Indigenous research leadership, representation and ways of working. Respondents recognized high levels of trust amongst members, rated "good communication and coordination with participants" highly, and "facilitating collaboration" as the CRE's most strongly recognized achievement. In collaboration and information-sharing networks, average path length remained low in 2017 and 2019, indicating good small-world network properties for relaying information. On average, respondents shared information and collaborated with more CRE members in 2017 than 2019. However, in both 2017 and 2019 there were new collaborations and information-sharing outside of direct collaborations. CRE-IQI outcomes included: evidence generation; knowledge transfer and skills development in quality improvement; research capacity-building, career development; mentoring; grant support; development of new projects; health service support; and policy impact. CONCLUSIONS: This study shows the utility of network analysis in evaluating the functioning, and collaboration, at the individual, organizational and health system levels, of an innovation platform, and adds to our understanding of factors enabling successful innovation platforms.

Systems integration to promote the mental health of Aboriginal and Torres Strait Islander children: protocol for a community-driven continuous quality improvement approach.

BACKGROUND: Systems integration to promote the mental health of Aboriginal and Torres Strait Islander children works towards developing a spectrum of effective, community-based services and supports. These services and supports are organised into a coordinated network, build meaningful partnerships with families and address their cultural and linguistic needs, to help children to function better at home, in school, in the community, and throughout life. This study is conducted in partnership with primary healthcare (PHC) and other services in three diverse Indigenous Australian communities. It entails conceptualising, co-designing, implementing, and evaluating the effectiveness of systems integration to promote the mental health and wellbeing of Indigenous school-aged children (4-17 years). This paper outlines a protocol for implementing such complex community-driven research. METHODS/DESIGN: Using continuous quality improvement processes, community co-designed strategies for improved systems integration will be informed by narratives from yarning circles with Indigenous children and service providers, and quantitative data from surveys of service providers and audits of PHC client records and intersectoral systems. Agreed strategies to improve the integration of community-based services and supports will be modelled using microsimulation software, with a preferred model implemented in each community. The evaluation will investigate changes in the: 1) availability of services that are community-driven, youth-informed and culturally competent; 2) extent of collaborative service networks; 3) identification by PHC services of children's social and emotional wellbeing concerns; and 4) ratio of children receiving services to identified need. Costs and benefits of improvements to systems integration will also be calculated. DISCUSSION: The study will provide evidence-informed, community-driven, and tested models that can be used for implementing systems integration to promote the mental health and wellbeing of Indigenous children. It will identify the situational enablers and barriers that impact systems integration and determine the extent to which systems integration improves service availability, systems and child outcomes. Evidence for the cost effectiveness of systems-level integration will contribute to national mental health policy reform.

Using developmental evaluation to enhance continuous reflection, learning and adaptation of an innovation platform in Australian Indigenous primary healthcare.

Effective efforts to strengthen health systems need diverse, multi-stakeholder networks working together on complex or 'wicked' problems such as prevention and control of chronic diseases, solutions to which go beyond the role and capability of one organisation. The contextual complexities inherent in 'wicked' problems mean that solutions warrant a systems approach that encompasses innovation and new ways of thinking about, facilitating and implementing collective decision-making processes and change practices.Innovation platforms are a mechanism for facilitating communication and collaboration among diverse stakeholders, promoting joint action and stimulating innovation. Developmental evaluation is an approach that is increasingly being used to evaluate innovative and emergent programmes and projects, as it enables evaluators to provide real-time feedback so that evaluation findings can be used to guide development and adaptations. Developmental evaluation emphasises learning and adaptation, and aligns well with the implementation of innovation platforms that have continuous reflection, learning and adaptation as a specific design principle.Here, we outline our rationale for applying a developmental evaluation to enhance the formation, functioning and outcomes of an innovation platform aimed at accelerating and strengthening large-scale quality improvement efforts in Australian Aboriginal and Torres Strait Islander primary healthcare. We provide examples to explain how the developmental evaluation findings were used for adaptation of the innovation platform and assess to what extent our application of developmental evaluation was consistent with, and reflective of, its essential principles.Our evaluation aligned strongly with the principles of developmental evaluation, and the approach we took was well suited to situations with a developmental purpose, innovation niche and complexity such as innovation platforms. As a result, along with the increasing interest in multi-stakeholder platforms (e.g. innovation platforms) and the inherent challenges with evaluating these complex networks, we anticipate our use of this approach being of interest globally.

Working well: a systematic scoping review of the Indigenous primary healthcare workforce development literature.

BACKGROUND: Strong and effective workforce models are essential for improving comprehensive Indigenous primary healthcare service (PHC) provision to Indigenous peoples in Canada, Australia, New Zealand and the USA (CANZUS nations). This review systematically scoped the literature for studies that described or evaluated models and systems that support the sustainability, capacity or growth of the Indigenous PHC workforce to provide effective PHC provision. METHODS: Eleven databases, 10 websites and clearinghouses, and the reference lists of 5 review articles were searched for relevant studies from CANZUS nations published in English from 2000 to 2017. A process of thematic analysis was utilised to identify key conditions, strategies and outcomes of Indigenous PHC workforce development reported in the literature. RESULTS: Overall, 28 studies were found. Studies reported enabling conditions for workforce development as government funding and appropriate regulation, support and advocacy by professional organisations; community engagement; PHC leadership, supervision and support; and practitioner Indigeneity, motivation, power equality and wellbeing. Strategies focused on enhancing recruitment and retention; strengthening roles, capacity and teamwork; and improving supervision, mentoring and support. Only 12/28 studies were evaluations, and these studies were generally of weak quality. These studies reported impacts of improved workforce sustainability, workforce capacity, resourcing/growth and healthcare performance improvements. CONCLUSIONS: PHCs can strengthen their workforce models by bringing together healthcare providers to consider how these strategies and enabling conditions can be improved to meet the healthcare and health needs of the local community. Improvement is also needed in the quality of evidence relating to particular strategies to guide practice.

Health workforce cultural competency interventions: a systematic scoping review.

BACKGROUND: Addressing health workforce cultural competence is a common approach to improving health service quality for culturally and ethnically diverse groups. Research evidence in this area is primarily focused on cultural competency training and its effects on practitioners' knowledge, attitudes, skills and behaviour. While improvements in measures of healthcare practitioner cultural competency and other healthcare outcomes have been reported, there are concerns around evidence strength and quality. This scoping review reports on the intervention strategies, outcomes, and measures of included studies with the purpose of informing the implementation and evaluation of future interventions to improve health workforce cultural competence. METHODS: This systematic scoping review was completed as part of a larger systematic literature search conducted on cultural competence intervention evaluations in health care in Canada, the United States, Australia and New Zealand published from 2006 to 2015. Overall, 64 studies on cultural competency interventions were found, with 16 aimed directly at the health workforce. RESULTS: There was significant heterogeneity in workforce intervention strategies, measures and outcomes reported across studies making comparisons of intervention effects difficult. The two main workforce intervention strategies identified were cultural competency training and other professional development interventions including other training and mentoring. Positive outcomes were commonly reported for improved practitioner knowledge (9/16), skills (7/16), and attitudes/beliefs (5/16). Although health care (6/16) and health (2/16) outcomes were reported in some studies there was very limited evidence of positive intervention impacts. Only four studies utilised existing validated measurement tools to assess intervention outcomes. CONCLUSION: Training and development of the health workforce remain a principle strategy towards the goal of improved cultural competence in health services and systems. Diverse approaches are available to increase health workforce cultural competence. However, the effects of interventions beyond practitioner knowledge and attitudes remains unclear. Assessment of practitioner behavioural outcomes as well as measures of intervention impact on healthcare and health outcomes are needed to build a stronger evidence base.

Implementing health promotion tools in Australian Indigenous primary health care.

BACKGROUND: In Australia, significant resources have been invested in producing health promotion best practice guidelines, frameworks and tools (herein referred to as health promotion tools) as a strategy to improve Indigenous health promotion programmes. Yet, there has been very little rigorous implementation research about whether or how health promotion tools are implemented. This paper theorizes the complex processes of health promotion tool implementation in Indigenous comprehensive primary healthcare services. METHODS: Data were derived from published and grey literature about the development and the implementation of four Indigenous health promotion tools. Tools were theoretically sampled to account for the key implementation types described in the literature. Data were analysed using the grounded-theory methods of coding and constant comparison with construct a theoretical implementation model. RESULTS: An Indigenous Health Promotion Tool Implementation Model was developed. Implementation is a social process, whereby researchers, practitioners and community members collectively interacted in creating culturally responsive health promotion to the common purpose of facilitating empowerment. The implementation of health promotion tools was influenced by the presence of change agents; a commitment to reciprocity and organizational governance and resourcing. CONCLUSION: The Indigenous Health Promotion Tool Implementation Model assists in explaining how health promotion tools are implemented and the conditions that influence these actions. Rather than simply developing more health promotion tools, our study suggests that continuous investment in developing conditions that support empowering implementation processes are required to maximize the beneficial impacts and effectiveness of health promotion tools.

Organisational systems' approaches to improving cultural competence in healthcare: a systematic scoping review of the literature.

INTRODUCTION: Healthcare organisations serve clients from diverse Indigenous and other ethnic and racial groups on a daily basis, and require appropriate client-centred systems and services for provision of optimal healthcare. Despite advocacy for systems-level approaches to cultural competence, the primary focus in the literature remains on competency strategies aimed at health promotion initiatives, workforce development and student education. This paper aims to bridge the gap in available evidence about systems approaches to cultural competence by systematically mapping key concepts, types of evidence, and gaps in research. METHODS: A literature search was completed as part of a larger systematic search of evaluations and measures 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 from 2002 to 2015. Overall, 109 studies were found, with 15 evaluating systems-level interventions or describing measurements. Thematic analysis was used to identify key implementation principles, intervention strategies and outcomes reported. RESULTS: Twelve intervention and three measurement studies met our inclusion criteria. Key principles for implementing systems approaches were: user engagement, organisational readiness, and delivery across multiple sites. Two key types of intervention strategies to embed cultural competence within health systems were: audit and quality improvement approaches and service-level policies or strategies. Outcomes were found for organisational systems, the client/practitioner encounter, health, and at national policy level. DISCUSSION AND IMPLICATIONS: We could not determine the overall effectiveness of systems-level interventions to reform health systems because interventions were context-specific, there were too few comparative studies and studies did not use the same outcome measures. However, examined together, the intervention and measurement principles, strategies and outcomes provide a preliminary framework for implementation and evaluation of systems-level interventions to improve cultural competence. Identified gaps in the literature included a need for cost and effectiveness studies of systems approaches and explication of the effects of cultural competence on client experience. Further research is needed to explore the extent to which cultural competence improves health outcomes and reduces ethnic and racially-based healthcare disparities.

Does Indigenous health research have impact? A systematic review of reviews.

BACKGROUND: Aboriginal and Torres Strait Islander Australians (hereafter respectfully Indigenous Australians) claim that they have been over-researched without corresponding research benefit. This claim raises two questions. The first, which has been covered to some extent in the literature, is about what type(s) of research are likely to achieve benefits for Indigenous people. The second is how researchers report the impact of their research for Indigenous people. This systematic review of Indigenous health reviews addresses the second enquiry. METHODS: Fourteen electronic databases were systematically searched for Indigenous health reviews which met eligibility criteria. Two reviewers assessed their characteristics and methodological rigour using an a priori protocol. Three research hypotheses were stated and tested: (1) reviews address Indigenous health priority needs; (2) reviews adopt best practice guidelines on research conduct and reporting in respect to methodological transparency and rigour, as well as acceptability and appropriateness of research implementation to Indigenous people; and (3) reviews explicitly report the incremental impacts of the included studies and translation of research. We argue that if review authors explicitly address each of these three hypotheses, then the impact of research for Indigenous peoples' health would be explicated. RESULTS: Seventy-six reviews were included; comprising 55 journal articles and 21 Australian Government commissioned evidence review reports. While reviews are gaining prominence and recognition in Indigenous health research and increasing in number, breadth and complexity, there is little reporting of the impact of health research for Indigenous people. This finding raises questions about the relevance of these reviews for Indigenous people, their impact on policy and practice and how reviews have been commissioned, reported and evaluated. CONCLUSIONS: The findings of our study serve two main purposes. First, we have identified knowledge and methodological gaps in documenting Indigenous health research impact that can be addressed by researchers and policy makers. Second, the findings provide the justification for developing a framework allowing researchers and funding bodies to structure future Indigenous health research to improve the reporting and assessment of impact over time.

Family-centred interventions by primary healthcare services for Indigenous early childhood wellbeing in Australia, Canada, New Zealand and the United States: a systematic scoping review.

BACKGROUND: Primary healthcare services in Australia, Canada, New Zealand and the United States have embraced the concept of family-centred care as a promising approach to supporting and caring for the health of young Indigenous children and their families. This scoping review assesses the quality of the evidence base and identifies the published literature on family- centred interventions for Indigenous early childhood wellbeing. METHODS: Fourteen electronic databases, grey literature sources and the reference lists of Indigenous maternal and child health reviews were searched to identify relevant publications from 2000 to 2015. Studies were included if the intervention was: 1) focussed on Indigenous children aged from conception to 5 years from the abovementioned countries; 2) led by a primary healthcare service; 3) described or evaluated; and 4) scored greater than 50% against a validated scale for family-centredness. The study characteristics were extracted and quality rated. Reported aims, strategies, enablers and outcomes of family-centredcare were identified using grounded theory methods. RESULTS: Eighteen studies (reported in 25 publications) were included. Three were randomised controlled studies; most were qualitative and exploratory in design. More than half of the publications were published from 2012 to 2015. The overarching aim of interventions was to promote healthy families. Six key strategies were to: support family behaviours and self- care, increase maternal knowledge, strengthen links with the clinic, build the Indigenous workforce, promote cultural/ community connectedness and advocate for social determinants of health. Four enablers were: competent and compassionate program deliverers, flexibility of access, continuity and integration of healthcare, and culturally supportive care. Health outcomes were reported for Indigenous children (nutritional status; emotional/behavioural; and prevention of injury and illness); parents/caregivers (depression and substance abuse; and parenting knowledge, confidence and skills); health services (satisfaction; access, utilization and cost) and community/cultural revitalisation. DISCUSSION AND CONCLUSION: The evidence for family-centred interventions is in the early stages of development, but suggests promise for generating diverse healthcare outcomes for Indigenous children and their parents/caregivers, as well as satisfaction with and utilisation of healthcare, and community/cultural revitalisation. Further research pertaining to the role of fathers in family-centred care, and the effects and costs of interventions is needed.

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

BACKGROUND: Effective 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? METHODS: Eight 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. RESULTS: Six 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. CONCLUSIONS: Comparison 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.

Psycho-social resilience, vulnerability and suicide prevention: impact evaluation of a mentoring approach to modify suicide risk for remote Indigenous Australian students at boarding school.

BACKGROUND: The proposed study was developed in response to increased suicide risk identified in Aboriginal and Torres Strait Islander students who are compelled to attend boarding schools across Queensland when there is no secondary schooling provision in their remote home communities. It will investigate the impact of a multicomponent mentoring intervention to increase levels of psychosocial resilience. We aim to test the null hypothesis that students' resilience is not positively influenced by the intervention. The 5-year project was funded by the Australian National Health and Medical Research Council from December 2014. METHODS/DESIGN: An integrated mixed methods approach will be adopted; each component iteratively informing the other. Using an interrupted time series design, the primary research methods are quantitative: 1) assessment of change in students' resilience, educational outcomes and suicide risk; and 2) calculation of costs of the intervention. Secondary methods are qualitative: 3) a grounded theoretical model of the process of enhancing students' psychosocial resilience to protect against suicide. Additionally, there is a tertiary focus on capacity development: more experienced researchers in the team will provide research mentorship to less experienced researchers through regular meetings; while Indigenous team members provide cultural mentorship in research practices to non-Indigenous members. DISCUSSION: Australia's suicide prevention policy is progressive but a strong service delivery model is lacking, particularly for Indigenous peoples. The proposed research will potentially improve students' levels of resilience to mitigate against suicide risk. Additionally, it could reduce the economic and social costs of Indigenous youth suicide by obtaining agreement on what is good suicide prevention practice for remote Indigenous students who transition to boarding schools for education, and identifying the benefits-costs of an evidence-based multi-component mentoring intervention to improve resilience.

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

BACKGROUND: Evaluating 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. METHODS: Constructivist 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. RESULTS: Program 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. CONCLUSIONS: The 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.

No one's discussing the elephant in the room: contemplating questions of research impact and benefit in Aboriginal and Torres Strait Islander Australian health research.

BACKGROUND: There remains a concern that Indigenous Australians have been over-researched without corresponding improvements in their health; this trend is applicable to most Indigenous populations globally. This debate article has a dual purpose: 1) to open a frank conversation about the value of research to Indigenous Australian populations; and 2) to stimulate ways of thinking about potential resolutions to the lack of progress made in the Indigenous research benefit debate. DISCUSSION: Capturing the meaning of research benefit takes the form of ethical value-oriented methodological considerations in the decision-making processes of Indigenous research endeavours. Because research practices come from Western knowledge bases, attaining such positions in research means reconciling both Indigenous and Western knowledge systems to produce new methodologies that guide planning, evaluating and monitoring of research practices as necessary. Increasingly, more sophisticated performance measures have been implemented to ensure academic impact and benefits are captured. Assessing societal and other non-academic impacts and benefits however, has not been accorded corresponding attention. Research reform has only focussed on research translation in more recent years. The research impact debate must take account of the various standards of accountability (to whom), impact priorities (for whom), positive and negative impacts, and biases that operate in describing impact and measuring benefit. SUMMARY: A perennial question in Indigenous research discourse is whether the abundance of research conducted; purportedly to improve health, is justified and benefits Indigenous people in ways that are meaningful and valued by them. Different research stakeholders have different conceptions of the value and nature of research, its conduct, what it should achieve and the kinds of benefits expected. We need to work collaboratively and listen more closely to the voice of Indigenous Australians to better understand, demonstrate and measure health research benefits. The authors conclude that as an imperative, a systematic benefit assessment strategy that includes identification of research priorities and planning, monitoring and evaluation components needs to be developed and implemented across research projects. In Indigenous health research, this will often mean adopting a benefit-led approach by changing the way research is done and preferencing alternative research methodologies. As a point of departure to improving impact and reaching mutually beneficial outcomes for researchers and partners in Indigenous health research, we need to routinise the assessment of benefit from outset of research as one of the standards toward which we work.

Interventions to improve cultural competency in health care for Indigenous peoples of Australia, New Zealand, Canada and the USA: a systematic review.

PURPOSE: This article describes the characteristics and reviews the methodological quality of interventions designed to improve cultural competency in health care for Indigenous peoples of Australia, New Zealand, Canada and the USA. DATA SOURCES: A total of 17 electronic databases and 13 websites for the period of 2002-13. STUDY SELECTION: Studies were included if they evaluated an intervention strategy designed to improve cultural competency in health care for Indigenous peoples of Australia, New Zealand, the USA or Canada. DATA EXTRACTION: Information on the characteristics and methodological quality of included studies was extracted using standardized assessment tools. RESULTS OF DATA SYNTHESIS: Sixteen published evaluations of interventions to improve cultural competency in health care for Indigenous peoples were identified: 11 for Indigenous peoples of the USA and 5 for Indigenous Australians. The main types of intervention strategies were education and training of the health workforce, culturally specific health programs and recruitment of an Indigenous health workforce. Main positive outcomes reported were improvements in health professionals' confidence, and patients' satisfaction with and access to health care. The methodological quality of evaluations and the reporting of key methodological criteria were variable. Particular problems included weak study designs, low or no reporting of consent rates, confounding and non-validated measurement instruments. CONCLUSION: There is a lack of evidence from rigorous evaluations on the effectiveness of interventions for improving cultural competency in health care for Indigenous peoples. Future evaluations should employ more rigorous study designs and extend their measurement of outcomes beyond those relating to health professionals, to those relating to the health of Indigenous peoples.

Changing discourses in Aboriginal and Torres Strait Islander health research, 1914-2014.

Aboriginal and Torres Strait Islander people strongly assert that health research has contributed little to improving their health, in spite of its obvious potential. The health concerns of Aboriginal and Torres Strait Islander people were largely ignored in early research published in the MJA, which reflected broader colonial history and racial discourses. This began to change with the demise of scientific racism, and changed policies and political campaigns for equal treatment of Indigenous people after the Second World War. In response to pressure from Aboriginal and Torres Strait Islander people and organisations, in parallel to broader political struggles for Indigenous rights since the 1970s, there have been significant and measurable changes to Aboriginal and Torres Strait Islander health research. Many of these changes have been about the ethics of health research. Increasingly, Aboriginal and Torres Strait Islander researchers, communities and organisations are now controlling and decolonising health research to better meet their needs, in collaboration with non-Indigenous researchers and research organisations.

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.

The quantity, quality and characteristics of Aboriginal and Torres Strait Islander Australian mentoring literature: a systematic review.

BACKGROUND: Mentoring is a key predictor of empowerment and prospectively a game changer in the quest to improve health inequities. This systematic review reports on the state of evidence on mentoring for Indigenous Australians by identifying the quantity, nature, quality and characteristics of mentoring publications. METHODS: Thirteen databases were searched using specific search strings from 1983 - 2012. Grey literature was also canvassed. The resultant publications were mined to identify their outputs, nature, and quality. These were then conceptually mined for their characteristics to develop a model of mentoring that included the initiating environments, facilitating environments, operational strategies and outcomes. RESULTS: 771 citations were identified; 37 full text publications met inclusion criteria and were assessed. Fifteen were eligible for review. Four of five original research publications used strong qualitative research designs. No publications were found before 1999; the largest proportion concentrated in 2011 (n = 4). Facilitating environments included: mapping participants' socio-cultural and economic context; formal mentoring practices with internal flexibility; voluntary participation; integrated models with wrap-around services; mentor/staff competencies; and sustained funding. Mentoring strategies comprised: holistic scaffolding approaches; respectful, trusting, one-on-one mentoring relationships; knowledgeable mentors; regular contact; longer-term relationships and exit strategies; culturally-tailored programs; personal and social development opportunities; and specialised skills and learning opportunities. Outcomes varied in accordance to program aims and included improvements in aspects of education and employment, offending behaviours, relationships, and personal, social and professional development. CONCLUSION: Little research explored the effectiveness of mentoring, captured its impact qualitatively or quantitatively, developed appropriate measures or assessed its cost-effectiveness. There is a real need to evaluate programs particularly in terms of outcomes and, given there were no economic evaluations, costs. Commitments to improving Indigenous Australian mentoring rely on changes to funding structures and attitudes toward research. There was insufficient evidence to confidently prescribe a best practice model. Sufficient frequency of qualitative reporting between publications concluded that mentoring is a valuable empowerment strategy in the areas of health and wellbeing, education and employment and as a remedial and preventative measure in reducing offending behaviours. An evidence-informed mentoring model would take into account the key findings of the review.