Factors influencing the community participation approaches used in Aedes mosquito management in the Torres Strait, Australia.

BACKGROUND: Aedes-borne disease risk is increasing in tropical and sub-tropical regions across the globe. While Aedes-borne disease continues to disproportionally affect low- and middle-income countries, parts of high-income countries, such as the Torres Strait region in Australia are also at risk. The Torres Strait is a group of islands located between Cape York Peninsula in far north Queensland, Australia and Papua New Guinea. The Torres Strait has both Aedes albopictus and Aedes aegypti and is close to Papua New Guinea where dengue fever is endemic. Managing Aedes-borne disease risk requires a range of strategies, including community participation. Existing research shows that high-income countries tend to favour government-led (top-down) informing approaches when engaging communities in Aedes mosquito management. Little is known about the factors that influence the choice of community participation approaches in Aedes mosquito management particularly in a high-income country setting, such as Australia. This research contributes to filling this knowledge gap by exploring the community participation approaches used in Aedes mosquito management and the factors influencing these choices in the Torres Strait. METHODS: 16 semi-structured interviews were conducted with local government and state government agencies working in Aedes mosquito management in the Torres Strait. Six key mosquito management plans and policies were also reviewed. Thematic analysis was used to identify, analyse and attribute meaning from the data collected. RESULTS: A range of community participation approaches were used within the two main Aedes mosquito management programs (Aedes albopictus Elimination Program and the Torres Strait Island Regional Council, Environmental Health Program) in the Torres Strait. These approaches included door-to-door inspections, awareness raising strategies, and community clean-up events. Approaches were chosen for reasons related to regulations, attitude and beliefs, and resourcing. CONCLUSIONS: This study revealed the use of both top-down and bottom-up approaches to engaging the community in Aedes mosquito management in the Torres Strait. These findings contribute to a better understanding of why bottom-up approaches are used, which is valuable for shaping future policy decisions. This study also provides suggestions on ways to enhance community participation in the Torres Strait, which could also be considered in other similar tropical regions.

The facilitators and barriers to exercise in the Noongar Aboriginal population in Perth, Australia.

Indigenous Standpoint Theory forms the epistemological foundation for this study and methodological choices were made within this theoretical framework to ensure culturally responsive research processes that engaged the Indigenous agenda of self-determination and rights. The objectives of this research were to determine: (i) Indigenous perceptions of the facilitators and barriers to exercise; (ii) The potential feasibility and sustainability of an exercise intervention. In this context, Participatory Action Research methods were used to design the data-gathering instrument for the study-a questionnaire, co-designed with the Noongar Aboriginal community of Perth, Western Australia. This self-administered questionnaire, distributed to participants by email, post and manual delivery, sought to elicit the factors that impact uptake and retention of regular exercise activities. Questionnaire data included individual demographic detail and specific question responses on labelled 5 point Likert Scales. Specific question responses were tabulated by Likert Scale label category and the response distribution for each question was enumerated. Simple descriptive statistics (measures of central tendency and variance) were used to characterize the data set and the Chi squared test was used to evaluate frequency differences between males and females. A total of 133 participants (71 females) completed the questionnaire. The results indicated that people valued exercise. The most common barriers indicated by participants were exercising with an injury (63%), changing diet (58%), finding time to exercise every day (55%) and exercising the next day with pain from exercising the day before (54%). A larger proportion of males (34%) than females (24%) reported greater ease in finding time to exercise every day (p < 0.05). Facilitators mainly related to the potential social and community benefits of exercising with other people, preferably in small groups, and the importance of a culturally secure venue. These findings shed light on what a culturally secure exercise programme might involve for the Noongar community. As this may have implications for other Aboriginal and Torres Strait Islander and international First Nations' Peoples, more focused research is needed on the place of traditional physical activities and the nature of culturally secure exercise programmes and spaces to enable wider application.

A qualitative descriptive study of a novel nurse-led skin cancer screening model in rural Australia.

BACKGROUND: People residing in rural areas have higher rates of skin cancer and face barriers to accessing care. Models of skin cancer care addressing the specific needs of rural communities and overcoming specific challenges are required, but literature is scarce. This study aimed to describe the elements of a nurse-led skin cancer model in rural Victoria using qualitative methodology and programme logic to inform implementation and ongoing sustainability. METHODS: Qualitative descriptive design. Semi-structured interviews were conducted with key stakeholders involved in the skin cancer model, namely health service executive management, clinical staff, and administration staff. Interviews were audio-recorded and transcribed verbatim. Transcripts were thematically analysed independently by two researchers before themes were compared and refined. A programme logic model was developed to organise themes into contextual elements, inputs, activities and anticipated outcomes; it was also used as a visual tool to aid discussions with key stakeholders. Member checking of the logic model occurred to verify interpretation. This programme logic model will be refined throughout the implementation phase, and again after three years of service delivery. RESULTS: Eight stakeholders participated in interviews. Thematic analysis identified three major themes: the influence of the local rural context, the elements of the model, and "making it happen'. These major themes and accompanying sub-themes were mapped to the programme logic model by contextual elements (rural locale, health service access barriers, burden of disease), key inputs (promotion, human resources including appropriate nurse training and leadership) and 'making it happen' (governance including referral pathways, flexible and sustained funding, and partnerships). The anticipated outcomes identified include skin cancer care delivered locally, timely access, career development for nurses, and decreased skin cancer burden. CONCLUSION: An initiative that is place-based and community driven in response to consumer demand addresses key system barriers to earlier detection of skin cancers. It is anticipated to result in flow-on reductions in skin cancer disease burden. Programme logic was useful to both describe the initiative and as a visual tool for discussions, with the potential to inform wider health service efforts to address system barriers and bottlenecks.

Community participation and empowerment approaches to Aedes mosquito management in high-income countries: a scoping review.

High-income countries (HICs) in sub-tropical and tropical regions are at an increasing risk of Aedes mosquito-borne disease (MBD) outbreaks such as dengue fever. As the Aedes mosquito predominately lives and breeds in and around people's homes, community participation in MBD management is an important part of preventing MBD outbreaks. Historically, government-led strategies have dominated community participation efforts as opposed to strategies co-designed or led by the community. A scoping review was conducted to describe the community participation and empowering approaches used in Aedes mosquito management specifically in HICs, and to identify any reported outcomes of these methods. A systematic search of peer-reviewed literature using electronic databases Medline (OVID), Web of Science, Scopus and ProQuest-Science and Technology as well as grey literature, found 19 studies that matched the review criteria. The review findings highlight a lack of empirical evidence to inform participatory and empowering approaches to mosquito management in HICs. Moreover, the rationale for using predominantly government-led approaches is not clear. Further research is required to better understand best approaches and barriers to employing empowering approaches in mosquito management in HICs.

Practitioner perceptions of the health of Australian First Nations' Peoples: Preliminary findings.

OBJECTIVE: To probe health practitioner perceptions of Australian First Nations' Peoples' health and to compare these with reported burden of disease, social determinants and culturally safe health systems data. DESIGN: An online survey tool was used to collect self-reported responses from health practitioners to answer literature-derived questions regarding underlying issues in Australian First Nations' Peoples' health. SETTING: Responses to the survey were sought from rural and urban health service locations across all Australian states and territories. PARTICIPANTS: Allied health, nursing, pharmacy, psychology, social work and related discipline students and practitioners currently working or studying in Australia. MAIN OUTCOME MEASURE(S): Degrees of correspondence between health discipline student and practitioner perceptions on 'major health issues' and 'health systems issues' and published population health and health systems data. Metrics for 'connectedness to' and 'preparedness to engage with' Australian First Nations' Peoples were also reported. RESULTS: Significant differences between practitioner perceptions of 'major health issues' and the disease burden/social determinants published evidence, and with the 'culturally safe health systems' published evidence, were noted. Positive impacts of social and professional relationships (connectedness) between practitioners and First Nations' Peoples were demonstrated. CONCLUSIONS: The inclusion of basic population health and culturally safe health systems training in curricula for all genres of health practitioners appears to be indicated by these findings. Further, a meaningful role for the intentional nurture of social and professional relationships with Australian First Nations' Peoples across all health disciplines is suggested as part of efforts to address health systems and equity issues.

Facilitators of community participation in an Aboriginal sexual health promotion initiative.

INTRODUCTION: Community participation is a collaborative process aimed at achieving community-identified outcomes. However, approaches to community participation within Aboriginal health promotion initiatives have been inconsistent and not well documented. Smart and Deadly was a community-led initiative to develop sexual health promotion resources with young Aboriginal people in regional Victoria, Australia. The principles of community-centred practice, authentic participatory processes and respect for the local cultural context guided the initiative. The aim of this article is to report factors that facilitated community participation undertaken in the Smart and Deadly initiative to inform future projects and provide further evidence in demonstrating the value of such approaches. METHODS: A summative evaluation of the Smart and Deadly initiative was undertaken approximately 2 years after the initiative ended. Five focus groups and 13 interviews were conducted with a purposive sample of 32 participants who were involved with Smart and Deadly in one of the following ways: project participant, stakeholder or project partner, or project developer or designer. A deductive content analysis was undertaken and themes were compared to the YARN model, which was specifically created for planning and evaluating community participation strategies relating to Aboriginal sexual health promotion. RESULTS: A number of factors that facilitated community participation approaches used in Smart and Deadly were identified. The overarching theme was that trust was the foundation upon which the facilitators of community participation ensued. These facilitators were cultural safety and cultural literacy, community control, and legacy and sustainability. Whilst the YARN model was highly productive in identifying these facilitators of community participation, the model did not have provision for the element of trust between workers and community. Given the importance of trust between the project team and the Aboriginal community in the Smart and Deadly initiative, a suggested revision to the YARN model is that trust is included as the basis upon which YARN model factors are predicated. CONCLUSIONS: Adding trust to the YARN model as a basis upon which YARN model factors are grounded assists future Aboriginal health promotion projects in ensuring community participation approaches are more likely to be acceptable to the Aboriginal community.

Are insights from Indigenous health shaping a paradigm shift in health promotion praxis in Australia?

Health promotion really is at a cross-road. Traditionally guided by the Ottawa Charter, it has been thought of as principle-guided actions, processes and technique, as well as outcomes or results. Health promotion has been characterised by its products and some even call it theory. In Australia, public funding for health promotion has, for many years, shaped its practice into behaviour change interventions. However, governments around the country are reconsidering their investments, evidenced by ideologically motivated policy shifts and associated substantial funding cuts. Recently, themes of empowerment, community control and community agency have emerged as new directions for future health promotion praxis and reports of activism-based approaches that seek to mobilise community energies around sexual health inequity have started to appear in the literature. Noting parallel developments in the social determinants and social change discourses, this paper posits that cutting edge health promotion efforts by Indigenous communities in Australia are shaping a new approach with potentially global application.

The Torres Indigenous Hip Hop Project: evaluating the use of performing arts as a medium for sexual health promotion.

ISSUE ADDRESSED: The Torres Indigenous Hip Hop Project (the Project) was conducted in the Torres and Northern Peninsula Area of Queensland during early 2010. This paper provides a critical analysis of project outcomes and identifies criteria that may form a suitable framework for the assessment of proposals for sexual health promotion using performing arts-based approaches in Aboriginal and Torres Strait Islander settings. METHODS: A case study method was used. The first phase of analysis assessed whether project objectives were met using data collected during project planning and implementation. The second phase used these findings, augmented by interviews with key personnel, to respond to the question 'How could this be done better?'. RESULTS: The Project required significant human and organisational implementation support. The project was successful in facilitating event-specific community mobilisation. It raised awareness of sexual health disadvantage and engaged effectively with the target group. It laid important groundwork to progress school-based and community mechanisms to address regional youth disadvantage. Against these benefits are issues of opportunity cost and the need for ongoing resources to capitalise on the opportunities created. CONCLUSIONS: With substantial support and planning, such approaches can play an important role in engaging young people and bridging the gap between clinical interventions and improvements in health deriving from community-driven strategies. SO WHAT? This paper contributes to existing literature by identifying key elements of an effective approach to using performing arts in sexual health promotion in Aboriginal and Torres Strait Islander settings. It also provides guidance when consideration is being given to investment in resource-intensive health promotion initiatives.

At the cultural interface: A systematic review of study characteristics and cultural integrity from twenty years of randomised controlled trials with Indigenous participants.

Purpose and aim: To identify and describe characteristics of Randomised Control Trial (RCT) design, implementation, and interpretation with a view tostrengtheningen the cultural integrity and scientific quality of this genre of research when used with, for and by Indigenous peoples. Issue: RCTs are widely regarded as the 'gold standard' method for evaluating the efficacy of an intervention. However, issues of cultural acceptability and higher attrition rates among RCT participants from diverse populations, including Indigenous participants, have been reported. A better understanding of cultural acceptability and attrition rates of RCTs has the potential to impact the translation of findings into effective policies, programs and practice. Method: A search of four electronic databases identified papers describing RCTs enrolling exclusively Australian Indigenous peoples over a 20-year period. The RCTs were assessed using: The Effective Public Health Practice Project's Quality Assessment Tool (EPHPP) and the Aboriginal & Torres Strait Islander Quality Appraisal Tool (QAT). The scores for each paper and the average scores of all papers were visualised using a Microsoft Excel™ Filled Radar Plot. Results: Seventeen trials met the inclusion criteria. There was wide variation in the quality of the included trials as assessed by the EPHPP and almost universally poor results when assessed for cultural appropriateness and integrity by the QAT. Conclusion: The value of the RCT research method, when applied to ultimately improve Australian Indigenous peoples' health, is diminished if issues of cultural integrity are not intrinsic to study design and execution. Our review found that it is feasible to have an RCT with both strong cultural integrity and high scientific quality. Attention to cultural integrity and community engagement, along with methodological rigour, may strengthen community ownership and contribute to more successful study adherence and potentially more effective translation of study findings into policy and practice.

Youth and Relationship Networks (YARNS): mobilising communities for sexual health.

ISSUE ADDRESSED: Community participation is vital if sexual health disadvantage among Aboriginal and Torres Strait Islander young people is to be addressed, yet there is a paucity of literature examining this issue. METHODS: The development, nature and impact of a community participation strategy for sexual health, implemented in two North Queensland sites, provided the opportunity for a systematic study, using qualitative and grounded theory analytic methods, of the factors that enable and constrain community participation in this context. A total of 30 people participated, in individual interviews and focus groups. RESULTS: The community participation strategy was fundamental to the development of culturally and community congruent sexual health initiatives. There were also signs of a changing discourse in community around sexual health. Factors that enabled effective community participation involved individual attributes, structured group processes, organisational support, empowering external relationships, a culturally sensitive strategy and enhanced health and wellbeing. CONCLUSION: The model developed here identifies factors that enable community participation and mobilisation, thus providing a valuable tool for health practitioners seeking to plan and evaluate strategies that address entrenched disadvantage in Aboriginal and Torres Strait Islander populations.

Hip hopping the gap--performing arts approaches to sexual health disadvantage in young people in remote settings.

OBJECTIVE: Closing the gap in Indigenous health and wellbeing in remote settings in the Torres Strait and Northern Peninsula Area of Far North Queensland (FNQ) includes addressing a well-documented sexual health disadvantage among young people. Community mobilization around the underlying risk factors influencing sexual health is required. METHOD: Performing-arts-based workshops were conducted in schools and after-school venues in four remote Aboriginal and Torres Strait islander locations in FNQ in early 2010, to initiate consciousness-raising around the real dimensions of youth sexual health risk. Specific objectives included strengthening operational partnerships at school-level and developing ongoing consultative processes in each location for sexual health reference group development. RESULTS: Results include a significantly strengthened productive partnership with primary and high schools in each location and sixteen production-ready hip hop songs exploring a range of physical, emotional and sexual health themes authored by the students and recorded on site. Additional outcomes included the willingness of community councils and civil society organizations to support local sexual health reference group activity. CONCLUSIONS: This initiative, the Indigenous Hip Hop Project, although accompanied by opportunity costs including alternative, more core business uses of staff time and program budget, has demonstrated the power of tapping the creative energy of young people at risk and the potential for mobilizing communities to activism around sexual health disadvantage.

Physical Activity and Self-Reported Metabolic Syndrome Risk Factors in the Aboriginal Population in Perth, Australia, Measured Using an Adaptation of the Global Physical Activity Questionnaire (GPAQ).

Background: Complex, ongoing social factors have led to a context where metabolic syndrome (MetS) is disproportionately high in Aboriginal Australians. MetS is characterised by insulin resistance, abdominal obesity, hypertension, hypertriglyceridemia, high blood-sugar and low HDL-C. This descriptive study aimed to document physical activity levels, including domains and intensity and sedentary behaviour, and MetS risk factors in the Perth Aboriginal (predominately Noongar) community. Methods: The Global Physical Activity Questionnaire (GPAQ), together with a questionnaire on self-reported MetS risk factors, was circulated to community members for completion during 2014 (n = 129). Results: Data were analysed using chi-squared tests. The average (SD) age was 37.8 years (14) and BMI of 31.4 (8.2) kg/m2. Occupational, transport-related and leisure-time physical activity (PA) and sedentary intensities were reported across age categories. The median (interquartile range) daily sedentary time was 200 (78, 435), 240 (120, 420) and 180 (60, 300) minutes for the 18-25, 26-44 and 45+ year-olds, respectively (p = 0.973). Conclusions: An in-depth understanding of the types, frequencies and intensities of PA reported for the Perth Aboriginal community is important to implementing targeted strategies to reduce the prevalence of chronic disease in this context. Future efforts collaborating with community should aim to reduce the risk factors associated with MetS and improve quality of life.

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

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

The Young Person Check: screening for sexually transmitted infections and chronic disease risk in remote Aboriginal and Torres Strait Islander youth.

OBJECTIVE: This paper describes the implementation and selected outcomes of the Young Person Check (YPC), a high-coverage screening program in far north Queensland targeting remote youth aged 15-24 years for sexually transmissible infections (STI) and chronic disease risk. The YPC was conducted 19 times in eight discrete remote communities and one community cluster between 2009 and 2012. METHODS: Narrative description of consultation processes, YPC planning, recruitment strategies, logistics, screen design, additional costs and data management; analysis of coverage by location, age group and gender, selected STI management outcomes, and clinic-based STI testing separate from YPCs. RESULTS: A total of 3,686 episodes of care were delivered, including 3,083 to Indigenous youth aged 15-24 years. Overall coverage of the 15-24 population was 73% for females and 72% for males. Median time to treatment for chlamydia/gonorrhoea cases was 13 days and 63% of cases had at least one contact treated. Clinic-based STI testing did not decrease. CONCLUSIONS: Positive outcomes of the YPC program, including satisfactory participation, rest on a rigorous approach to planning, recruitment and implementation; provision for STI follow-up; and data management. IMPLICATIONS: Testing and treatment strategies form an important element of efforts to address endemic STI and reduce HIV risk in remote Australian populations. Complementary population testing strategies will continue to be utilised and may contribute, if coverage is satisfactory. Programs such as the YPC should be considered in settings where the conditions outlined here can be met.

Should we change the focus of health promotion in sexual health clinics?

In a response to the recent article by Rudiger Pitroff and Elizabeth Goodburn on changing the focus of health promotion in sexual health clinics, Crouch and Fagan draw attention to the confusion among practitioners between brief interventions in clinics (health education) and the actual nature and scope of sexual health promotion. The response refocuses attention on the Ottawa Charter for Health Promotion and on the social determinants of sexual health inequity as appropriate design drivers of a pilot initiative proposed by Pitroff and Goodburn to re-orient sexual health service provision around the real needs of its clients.

Immunization and the Millennium Development Goals: progress and challenges in Latin America and the Caribbean.

The child mortality rate has been greatly reduced in Latin America and the Caribbean (LAC). More than half of the gains in reducing child mortality are attributable to immunization. The Revolving Fund of the Pan American Health Organization contributed to this achievement by catalyzing policy innovations that sustained national immunization programs, such as vaccine legislation and budgetary decrees to ensure delivery of services. In addition to measuring the impact of immunization on the child mortality reduction target of the Millennium Development Goals in the LAC region, this paper provides a policy framework to ensure that the rest of the target is reached.

Progress in the control of hepatitis B infection in the Western Pacific Region.

Hepatitis B virus infection is a serious problem globally, and particularly in the Western Pacific Region where the population suffers disproportionately from the infection and its sequelae. By 2001, every immunization programme in the Region had included hepatitis B vaccine in their schedule. However, many challenges remain if every one of the 26 million children born in the 37 countries and areas of the Region each year is to be protected against hepatitis B infection. In 2003, the Regional Committee of the World Health Organization's Western Pacific Region resolved to improve hepatitis B control by making it one of two new pillars for strengthening the Expanded Programme on Immunization. The Committee endorsed the strategies of the Regional Plan to improve hepatitis B control through immunization, reducing chronic HBV infection (chronic carriage rate) to less than 1%, and aiming for coverage of at least 80% of the birth cohort in every district with three doses of hepatitis B vaccine by 2005. To help guide this process, an assessment was made of the progress to date, and is reported in this paper. Coverage data used in this evaluation were not independently verified, and could over-estimate progress made in some countries. Whilst there has indeed been great progress in the Region, a number of national programmes still lack the ability to reach all children with immunization services. Other major issues that need to be addressed are the challenges of delivering a timely birth dose, and for certain countries, the affordability of the vaccine over the short- and long-term.