Consolidated criteria for strengthening reporting of health research involving indigenous peoples: the CONSIDER statement.

BACKGROUND: Research reporting guidelines are increasingly commonplace and shown to improve the quality of published health research and health outcomes. Despite severe health inequities among Indigenous Peoples and the potential for research to address the causes, there is an extended legacy of health research exploiting Indigenous Peoples. This paper describes the development of the CONSolIDated critERtia for strengthening the reporting of health research involving Indigenous Peoples (CONSIDER) statement. METHODS: A collaborative prioritization process was conducted based on national and international statements and guidelines about Indigenous health research from the following nations (Peoples): Australia (Aboriginal and Torres Strait Islanders), Canada (First Nations Peoples, Métis), Hawaii (Native Hawaiian), New Zealand (Maori), Taiwan (Taiwan Indigenous Tribes), United States of America (First Nations Peoples) and Northern Scandinavian countries (Sami). A review of seven research guidelines was completed, and meta-synthesis was used to construct a reporting guideline checklist for transparent and comprehensive reporting of research involving Indigenous Peoples. RESULTS: A list of 88 possible checklist items was generated, reconciled, and categorized. Eight research domains and 17 criteria for the reporting of research involving Indigenous Peoples were identified. The research reporting domains were: (i) governance; (ii) relationships; (iii) prioritization; (iv) methodologies; (v) participation; (vi) capacity; (vii) analysis and findings; and (viii) dissemination. CONCLUSIONS: The CONSIDER statement is a collaborative synthesis and prioritization of national and international research statements and guidelines. The CONSIDER statement provides a checklist for the reporting of health research involving Indigenous peoples to strengthen research praxis and advance Indigenous health outcomes.

Capacity building of the Australian Aboriginal and Torres Strait Islander health researcher workforce: a narrative review.

BACKGROUND: This paper provides a narrative review that scopes and integrates the literature on the development and strengthening of the Australian Aboriginal and Torres Strait Islander health researcher workforce. The health researcher workforce is a critical, and oft overlooked, element in the health workforce, where the focus is usually on the clinical occupations and capabilities. Support and development of the Australian Aboriginal and Torres Strait Islander health researcher workforce is necessary to realise more effective health policies, a more robust wider health workforce, and evidence-led clinical care. This holds true internationally. It is critical to identify what approaches have resulted in increased numbers of Aboriginal and Torres Strait Islander people in health research, stronger local community partnerships with universities and industry, and research excellence and have contributed to evidence-led health workforce development strategies. METHODS: The search was for peer-reviewed journal articles between 2000 and early 2018 on capacity building of the Aboriginal and Torres Strait Islander health researcher workforce. Databases searched were CINAHL (EBSCO), PubMed, PsychINFO, LIt.search, and Google Scholar, combined with manual searches of select journals and citations in the grey literature. A coding scheme was developed to scan research coverage of various dimensions of health research capacity building. RESULTS: Twenty-four articles were identified. Eight focused on strengthening research capabilities of community members. A recurrent finding was the high research productivity of Aboriginal and Torres Strait Islander health researchers and strong interest in furthering research that makes a substantive contribution to community well-being. Action-based principles were derived from synthesis of the findings. Generally, research capacity building led to numerous gains in workforce development and improving health systems. CONCLUSIONS: There is a shortage of literature on health researcher workforce capacity building. National-level research on capacity building strategies is needed to support the continued success and sustainability of the Australian Aboriginal and Torres Strait Islander health researcher workforce. This research needs to build on the strengths of Aboriginal and Torres Strait Islander researchers. It also needs to identify clear and robust pathways to careers and stable employment in the health workforce, and health researcher workforce more specifically. This need is evident in all settler colonial nations (e.g. Canada, United States of America, New Zealand), and principles can be applied more broadly to other minoritised populations.

Educating for Indigenous Health Equity: An International Consensus Statement.

The determinants of health inequities between Indigenous and non-Indigenous populations include factors amenable to medical education's influence-for example, the competence of the medical workforce to provide effective and equitable care to Indigenous populations. Medical education institutions have an important role to play in eliminating these inequities. However, there is evidence that medical education is not adequately fulfilling this role and, in fact, may be complicit in perpetuating inequities.This article seeks to examine the factors underpinning medical education's role in Indigenous health inequity, to inform interventions to address these factors. The authors developed a consensus statement that synthesizes evidence from research, evaluation, and the collective experience of an international research collaboration including experts in Indigenous medical education. The statement describes foundational processes that limit Indigenous health development in medical education and articulates key principles that can be applied at multiple levels to advance Indigenous health equity.The authors recognize colonization, racism, and privilege as fundamental determinants of Indigenous health that are also deeply embedded in Western medical education. To contribute effectively to Indigenous health development, medical education institutions must engage in decolonization processes and address racism and privilege at curricular and institutional levels. Indigenous health curricula must be formalized and comprehensive, and must be consistently reinforced in all educational environments. Institutions' responsibilities extend to advocacy for health system and broader societal reform to reduce and eliminate health inequities. These activities must be adequately resourced and underpinned by investment in infrastructure and Indigenous leadership.

Enhanced primary mental healthcare for Indigenous Australians: service implementation strategies and perspectives of providers.

BACKGROUND: Improving access to culturally appropriate mental healthcare has been recognised as a key strategy to address the often greater burden of mental health issues experienced by Indigenous populations. We present data from the evaluation of a national attempt at improving access to culturally appropriate mental healthcare for Indigenous Australians through a mainstream primary mental healthcare program, the Access to Allied Psychological Services program, whilst specifically focusing on the implementation strategies and perspectives of service providers. METHODS: We conducted semi-structured interviews with 31 service providers (primary care agency staff, referrers, and mental health professionals) that were analysed thematically and descriptively. RESULTS: Agency-level implementation strategies to enhance service access and cultural appropriateness included: the conduct of local service needs assessments; Indigenous stakeholder consultation and partnership development; establishment of clinical governance frameworks; workforce recruitment, clinical/cultural training and supervision; stakeholder and referrer education; and service co-location at Indigenous health organisations. Dedicated provider-level strategies to ensure the cultural appropriateness of services were primarily aimed at the context and process of delivery (involving, flexible referral pathways, suitable locations, adaptation of client engagement and service feedback processes) and, to a lesser extent, the nature and content of interventions (provision of culturally adapted therapy). CONCLUSIONS: This study offers insights into key factors underpinning the successful national service implementation approach. Study findings highlight that concerted national attempts to enhance mainstream primary mental healthcare for Indigenous people are critically dependent on effective local agency- and provider-level strategies to optimise the integration, adaptation and broader utility of these services within local Indigenous community and healthcare service contexts. Despite the explicit provider focus, this study was limited by a lack of Indigenous stakeholder perspectives. Key study findings are of direct relevance to inform the future implementation and delivery of culturally appropriate primary mental healthcare programs for Indigenous populations in Australia and internationally.

Putting action into the revised Australian Medical Council standards on Aboriginal and Torres Strait Islander and Maori health.

Since 2006 the Australian Medical Council (AMC) accreditation standards have required medical schools to comprehensively address issues related to the health of Aboriginal and Torres Strait Islander peoples in Australia, and Maori in New Zealand. This has spanned areas of staff expertise, staff and student recruitment, curriculum and institutional leadership. These Indigenous specific standards have, until now, been absent for specialist medical college accreditation. The AMC revised its accreditation standards for specialist medical colleges in 2015, and for the first time included Indigenous specific standards. This commentary presents a guideline to support Australasian medical colleges' responsiveness to these Indigenous specific standards.

Understanding practitioner professionalism in Aboriginal and Torres Strait Islander health: lessons from student and registrar placements at an urban Aboriginal and Torres Strait Islander primary healthcare service.

Aboriginal and Torres Strait Islander peoples continue to be pathologised in medical curriculum, leaving graduates feeling unequipped to effectively work cross-culturally. These factors create barriers to culturally safe health care for Aboriginal and Torres Strait Islander peoples. In this pilot pre-post study, the learning experiences of seven medical students and four medical registrars undertaking clinical placements at an urban Aboriginal and Torres Strait Islander primary healthcare service in 2014 were followed. Through analysis and comparison of pre- and post-placement responses to a paper-based case study of a fictitious Aboriginal patient, four learning principles for medical professionalism were identified: student exposure to nuanced, complex and positive representations of Aboriginal peoples; positive practitioner role modelling; interpersonal skills that build trust and minimise patient-practitioner relational power imbalances; and knowledge, understanding and skills for providing patient-centred, holistic care. Though not exhaustive, these principles can increase the capacity of practitioners to foster culturally safe and optimal health care for Aboriginal peoples. Furthermore, competence and effectiveness in Aboriginal health care is an essential component of medical professionalism.

Health and wellbeing outcomes of programs for Indigenous Australians that include strategies to enable the expression of cultural identities: a systematic review.

Indigenous people have long maintained that strong cultural identities are critical to health and wellbeing. The purpose of this systematic review is to examine whether interventions that entail strategies to enable expression of cultural identities for Australian Indigenous peoples are associated with measurable improvements in health and wellbeing. Peer-reviewed articles that reported quantitatively expressed health and wellbeing outcomes involving Indigenous Australian participants only were included. The cultural intervention component was defined and assessed by Indigenous researchers on the team. A narrative analysis was conducted. The protocol was registered on PROSPERO (CRD42015027387). Thirteen articles describing eleven studies were identified, including one randomised control trial (RCT), one cluster RCT and two studies with non-randomised controls. Other studies reported on case series or cross-sectional studies. All except two studies described multiple intervention strategies. Eight studies showed significant improvement in at least one psychosocial, behavioural or clinical measure, with two showing a positive direction of effect and one showing no improvement. Publication bias may discourage researchers to report negative findings of these interventions. Although studies vary in quality, this review provides evidence that interventions that include opportunities for expression of cultural identities can have beneficial effects for Australian Indigenous peoples.

"Unwell while Aboriginal": iatrogenesis in Australian medical education and clinical case management.

INTRODUCTION: Attention to Aboriginal health has become mandatory in Australian medical education. In parallel, clinical management has increasingly used Aboriginality as an identifier in both decision making and reporting of morbidity and mortality. This focus is applauded in light of the gross inequalities in health outcomes between indigenous people and other Australians. METHODS: A purposive survey of relevant Australian and international literature was conducted to map the current state of play and identify concerns with efforts to teach cultural competence with Aboriginal people in medical schools and to provide "culturally appropriate" clinical care. The authors critically analyzed this literature in light of their experiences in teaching Aboriginal studies over six decades in many universities to generate examples of iatrogenic effects and possible responses. RESULTS AND DISCUSSION: Understanding how to most effectively embed Aboriginal content and perspectives in curriculum and how to best teach and assess these remains contested. This review canvasses these debates, arguing that well-intentioned efforts in medical education and clinical management can have iatrogenic impacts. Given the long history of racialization of Aboriginal people in Australian medicine and the relatively low levels of routine contact with Aboriginal people among students and clinicians, the review urges caution in compounding these iatrogenic effects and proposes strategies to combat or reduce them. CONCLUSION: Long overdue efforts to recognize gaps and inadequacies in medical education about Aboriginal people and their health and to provide equitable health services and improved health outcomes are needed and welcome. Such efforts need to be critically examined and rigorously evaluated to avoid the reproduction of pathologizing stereotypes and reductionist explanations for persistent poor outcomes for Aboriginal people.

Aboriginal and Torres Strait Islander Public Health: Online and Integrated into Core Master of Public Health Subjects.

The Master of Public Health (MPH) is an internationally recognised post-graduate qualification for building the public health workforce. In Australia, MPH graduate attributes include six Indigenous public health (IPH) competencies. The University of Melbourne MPH program includes five core subjects and ten specialisation streams, of which one is Indigenous health. Unless students complete this specialisation or electives in Indigenous health, it is possible for students to graduate without attaining the IPH competencies. To address this issue in a crowded and competitive curriculum an innovative approach to integrating the IPH competencies in core MPH subjects was developed. Five online modules that corresponded with the learning outcomes of the core public health subjects were developed, implemented and evaluated in 2015. This brief report outlines the conceptualisation, development, and description of the curriculum content; it also provides preliminary student evaluation and staff feedback on the integration project. Significance for public healthThis approach to a comprehensive, online, integrated Indigenous public health (IPH) curriculum is significant, as it ensures that all University of Melbourne Master of Public Health (MPH) graduates will have the competencies to positively contribute to Indigenous health status. A workforce that is attuned not only to the challenges of IPH, but also to the principles of self-determination, Indigenous agency and collaboration is better equipped to be comprised of ethical and judgment-safe practitioners. Additionally, the outlined approach of utilizing IPH content and examples into core MPH subjects ensures both the Australian relevance for an Australian-based health professional course and international appeal through the modules inclusion of International Indigenous case-studies and content. Furthermore, approaches learned in a challenging Indigenous Australian context are transferable and applicable to other IPH challenges in a local, national and global context.

Innovation in Indigenous Health and Medical Education: The Leaders in Indigenous Medical Education (LIME) Network as a Community of Practice.

PROBLEM: The Leaders in Indigenous Medical Education (LIME) Network aims to improve the quality and effectiveness of Indigenous health in medical education as well as best practice in the recruitment, retention, and graduation of Indigenous medical students. INTERVENTION: In this article we explore the utility of Etienne Wenger's "communities of practice" (CoP) concept in providing a theoretical framework to better understand the LIME Network as a form of social infrastructure to further knowledge and innovation in this important area of health care education reform. CONTEXT: The Network operates across all medical schools in Australia and New Zealand. OUTCOME: Utilizing a model of evaluation of communities of practice developed by Fung-Kee-Fung et al., we seek to analyze the outcomes of the LIME Network as a CoP and assess its approach and contribution to improving the implementation of Indigenous health in the medical curriculum and the graduation of Indigenous medical students. LESSONS LEARNED: By reflecting on the Network through a community of practice lens, this article highlights the synthesis between the LIME Network and Wenger's theory and provides a framework with which to measure Network outputs. It also posits an opportunity to better capture the impact of Network activities into the future to ensure that it remains a relevant and sustainable entity.

Improving access to primary mental healthcare for Indigenous Australians.

OBJECTIVE: To examine the uptake, population reach and outcomes of primary mental healthcare services provided to Indigenous Australians via the Access to Allied Psychological Services (ATAPS) program between 2003 and 2013, with particular reference to enhanced Indigenous ATAPS services introduced from 2010. METHOD: Utilising ATAPS program data from a national minimum data set and comparative population data, we conducted descriptive analyses, regression analyses and t-tests to examine the uptake of ATAPS services, provider agency level predictors of service reach, and preliminary outcome data on consumer level outcomes. RESULTS: Between 2003 and 2013, 15,450 Indigenous client referrals were made that resulted in 55,134 ATAPS sessions. National Indigenous service volume more than doubled between 2010 and 2012, following the introduction of enhanced Indigenous ATAPS services. Non-Indigenous ATAPS service volume of primary care agencies was uniquely predictive of Indigenous service reach. Preliminary analysis of limited consumer outcome data indicated positive treatment gains and the need to enhance future outcome data collection. CONCLUSIONS: Concerted national efforts to enhance mainstream primary mental healthcare programs can result in significant gains in access to mental healthcare for Indigenous populations.

The use of the International Classification of Functioning, Disability and Health to understand the health and functioning experiences of people with chronic conditions from the person perspective: a systematic review.

PURPOSE: This systematic review examines the literature to identify the context and extent of implementation of the International Classification of Functioning, Disability and Health (ICF) model to understand the experience of health and functioning in persons with chronic conditions from the person perspective. METHOD: The literature search was conducted through five electronic databases between 2001 and December 2012. Reference lists of included papers were also searched. Articles in which the ICF was used to understand the health and functioning experience of adults with chronic conditions from the person-perspective were included. Data were extracted and analysed to identify the year of publication, geographical location, health condition, context of ICF use, authors' remarks and identified limitations of the ICF. RESULTS: Thirty-seven qualitative and mixed-methods studies were included representing 18 countries and a range of chronic conditions. The ICF was found to be used to elicit and analyse people's narratives, with the majority of studies reporting that the ICF provides a comprehensive analysis of experiences and needs from the person perspective. Some limitations to its use and the need to classify the "personal factors" component were reported. CONCLUSION: The ICF has been used to provide a comprehensive understanding of health and functioning in persons with chronic conditions from the person perspective, although there are currently relatively few studies which have used the ICF in this context. Limitations regarding its use were reported which should be considered by users of the model and during its revision process. IMPLICATIONS FOR REHABILITATION: The ICF encourages a bio-psycho-social and person-centred approach to healthcare and may provide a useful tool for guiding clinical assessment and encouraging clinicians to consider the multitude of factors which impact health, which may result in more specific and individualised treatment targeted at individual needs. Using a common framework that can be understood across health disciplines may enhance interdisciplinary communication and collaboration, improving health care delivery. The ICF may be used to compare perspectives of individuals and their health professionals and to identify people's needs that are not adequately being addressed, which may have significant implications for improving healthcare provided and overall health outcomes.

Cultural competence in medical education: aligning the formal, informal and hidden curricula.

The concept of cultural competence has become reified by inclusion as an accreditation standard in the US and Canada, in New Zealand it is demanded through an Act of Parliament, and it pervades discussion in Australian medical education discourse. However, there is evidence that medical graduates feel poorly prepared to deliver cross-cultural care (Weissman et al. in J Am Med Assoc 294(9):1058-1067, 2005) and many commentators have questioned the effectiveness of cultural competence curricula. In this paper we apply Hafferty's taxonomy of curricula, the formal, informal and hidden curriculum (Hafferty in Acad Med 73(4):403-407, 1998), to cultural competence. Using an example across each of these curricular domains, we highlight the need for curricular congruence to support cultural competence development among learners. We argue that much of the focus on cultural competence has been in the realm of formal curricula, with existing informal and hidden curricula which may be at odds with the formal curriculum. The focus of the formal, informal and hidden curriculum, we contend, should be to address disparities in health care outcomes. In conclusion, we suggest that without congruence between formal, informal and hidden curricula, approaches to addressing disparity in health care outcomes in medical education may continue to represent reform without change.

The use of the international classification of functioning, disability and health (ICF) in indigenous healthcare: a systematic literature review.

INTRODUCTION: The International Classification of Functioning, Disability and Health (ICF) was endorsed by the World Health Organisation (WHO) in 2001 to obtain a comprehensive perspective of health and functioning of individuals and groups. Health disparities exist between Indigenous and non-Indigenous Australians and there is a need to understand the health experiences of Indigenous communities from Indigenous Australian's perspectives in order to develop and implement culturally appropriate and effective intervention strategies to improve Indigenous health. This systematic review examines the literature to identify the extent and context of use of the ICF in Indigenous healthcare, to provide the foundation on which to consider its potential use for understanding the health experiences of Indigenous communities from their perspective. METHODS: The search was conducted between May and June 2012 of five scientific and medical electronic databases: MEDLINE, Web of Science, CINAHL, Academic Search Complete and PsychInfo and six Indigenous-specific databases: AIATSIS, APAIS-health, ATSI-health, health and society, MAIS-ATSIS and RURAL. Reference lists of included papers were also searched. Articles which applied the ICF within an Indigenous context were selected. Quantitative and qualitative data were extracted and analysed by two independent reviewers. Agreement was reached by consensus. RESULTS: Five articles met the inclusion criteria however two of the articles were not exclusively in an Indigenous context. One article applied the ICF in the context of understanding the health experience and priorities of Indigenous people and a second study had a similar focus but used the revised version of the International Classification of Impairments, Disability and Handicap (ICIDH-2), the predecessor to the ICF. Four of the five papers involved Indigenous Australians, and one of the paper's participants were Indigenous (First Nation) Canadians. CONCLUSION: Literature referring to the use of the ICF with Indigenous populations is limited. The ICF has the potential to help understand the health and functioning experience of Indigenous persons from their perspective. Further research is required to determine if the ICF is a culturally appropriate tool and whether it is able to capture the Indigenous health experience or whether modification of the framework is necessary for use with this population.

Do indigenous health curricula in health science education reduce disparities in health care outcomes?

OBJECTIVE: To undertake a systematic literature review to determine the scope, rationales, and evaluation foci of indigenous health curricula included in university-based professional training of health care service providers. STUDY DESIGN: Systematic review. DATA SOURCES: We searched the Australasian Medical Index, ATSIhealth (Aboriginal and Torres Strait Islander Health Bibliography), CINAHL PLUS, MEDLINE, SCOPUS version 4, and Web of Science databases using relevant keywords. Our initial search identified 1247 articles and our refined search identified 57 articles. Thirty-six articles published between 1999 and 2011 that referred to indigenous health-related curricula within university health science courses were selected for review. DATA SYNTHESIS: While almost all the articles were explicit that improving indigenous health was an aim of their curriculum, none evaluated the impact of curricula on patient outcomes. CONCLUSION: There appears to be a widespread assumption in the literature that improving practitioner skills, knowledge and attitudes will lead to improvements in indigenous health outcomes. The literature showed evidence of efforts towards evaluating learner (student) outcomes, but no evidence of evaluation of patient outcomes. We need to begin to design methods that focus on evaluating the impacts of indigenous health curricula on patient outcomes, while continuing to investigate the impact of curricula on learner outcomes.

Medical schools as agents of change: socially accountable medical education.

Medical education reform can make an important contribution to the future health care of populations. Social accountability in medical education was defined by the World Health Organization in 1995, and an international movement for change is gathering momentum. While change can be enabled with policy levers, such as funding tied to achieving equity outcomes and systems of accreditation, medical schools and students themselves can lead the transformation agenda. An international movement for change and coalitions of medical schools with an interest in socially accountable medical education provide a "community of practice" that can drive change from within.

Exposing the hidden curriculum influencing medical education on the health of Indigenous people in Australia and New Zealand: the role of the Critical Reflection Tool.

The disparity in health status between Indigenous and non-Indigenous people in Australia and New Zealand is widely known, and efforts to address this through medical education are evidenced by initiatives such as the Committee of Deans of Australian Medical Schools' Indigenous Health Curriculum Framework. These efforts have focused primarily on formal curriculum reform. In this article, the authors discuss the role of the hidden curriculum in influencing the teaching and learning of Indigenous health (i.e., the health of Indigenous people) during medical training and suggest that in order to achieve significant changes in learning outcomes, there needs to be better alignment of the formal and hidden curriculum. They describe the Critical Reflection Tool as a potential resource through which educators might begin to identify the dimensions of their institution's hidden curricula. If used effectively, the process may guide institutions to better equip medical school graduates with the training necessary to advance changes in Indigenous health.