Health engagement: a systematic review of tools modifiable for use with vulnerable pregnant women.

OBJECTIVE: To examine available health engagement tools suitable to, or modifiable for, vulnerable pregnant populations. DESIGN: Systematic review. ELIGIBILITY CRITERIA: Original studies of tool development and validation related to health engagement, with abstract available in English, published between 2000 and 2022, sampling people receiving outpatient healthcare including pregnant women. DATA SOURCES: CINAHL Complete, Medline, EMBASE and PubMed were searched in April 2022. RISK OF BIAS: Study quality was independently assessed by two reviewers using an adapted COSMIN risk of bias quality appraisal checklist. Tools were also mapped against the Synergistic Health Engagement model, which centres on women's buy-in to maternity care. INCLUDED STUDIES: Nineteen studies were included from Canada, Germany, Italy, the Netherlands, Sweden, the UK and the USA. Four tools were used with pregnant populations, two tools with vulnerable non-pregnant populations, six tools measured patient-provider relationship, four measured patient activation, and three tools measured both relationship and activation. RESULTS: Tools that measured engagement in maternity care assessed some of the following constructs: communication or information sharing, woman-centred care, health guidance, shared decision-making, sufficient time, availability, provider attributes, discriminatory or respectful care. None of the maternity engagement tools assessed the key construct of buy-in. While non-maternity health engagement tools measured some elements of buy-in (self-care, feeling hopeful about treatment), other elements (disclosing risks to healthcare providers and acting on health advice), which are significant for vulnerable populations, were rarely measured. CONCLUSIONS AND IMPLICATIONS: Health engagement is hypothesised as the mechanism by which midwifery-led care reduces the risk of perinatal morbidity for vulnerable women. To test this hypothesis, a new assessment tool is required that addresses all the relevant constructs of the Synergistic Health Engagement model, developed for and psychometrically assessed in the target group. PROSPERO REGISTRATION NUMBER: CRD42020214102.

Inequitable use of health services for Indigenous mothers who experience stillbirth in Australia.

OBJECTIVES: The purpose of this study was to identify differences in health service expenditure on Indigenous and non-Indigenous women who experience a stillbirth, women's out-of-pocket costs, and health service use. METHODS: The project used a whole-of-population linked data set called "Maternity1000," which includes all women who gave birth in Queensland, Australia, between July 1, 2012, and June 30, 2018 (n = 396 158). Multivariable analysis was undertaken to assess differences in mean health service expenditure; and number of health care services accessed between Indigenous and non-Indigenous women who had a stillbirth from birth to twelve months postpartum. Costs are presented in 2019/20 Australian dollars. RESULTS: There was a total of 1864 babies stillborn to women in Queensland between July 1, 2012, and June 30, 2018, with 135 being born to Indigenous women and 1729 born to non-Indigenous women. There was significantly lower total expenditure per woman for Indigenous women compared with non-Indigenous women ($16 083 and $18 811, respectively). This was consistent across public hospital inpatient ($12 564 compared with $14 075), outpatient ($1127 compared with $1470), community-based services ($198 compared with $313), pharmaceuticals ($8 compared with $22), private hospital ($434 compared with $1265), and for individual out-of-pocket fees ($21 compared with $86). Mean expenditure on emergency department services per woman was higher for Indigenous women compared with non-Indigenous women ($947 compared with $643). Indigenous women who experienced a stillbirth accessed fewer general practitioners, allied health, specialist, obstetrics, and outpatient services, and fewer pathology and diagnostic test than their non-Indigenous counterparts. CONCLUSIONS: Inequities in access to health services exist between Indigenous and non-Indigenous women who experience a stillbirth.

Evaluation of a First Peoples-led, emotion-based pedagogical intervention to promote cultural safety in undergraduate non-Indigenous health professional students.

BACKGROUND: Undergraduate health students learn cultural safety in complex and emotional ways. Pedagogies that account for these complexities must be developed and evaluated. OBJECTIVES: To evaluate a First Peoples-led emotion-based pedagogical intervention on non-Indigenous health professional students' development towards cultural safety. DESIGN: A pre-post mixed-methods intervention design. SETTING AND PARTICIPANTS: All undergraduate health students undertaking a semester-long First Peoples cultural safety course (n = 395) were invited to participate. METHODS: The intervention involved students' written reflections and comfort (1 = very uncomfortable to 5 = very comfortable) with workshop content, using a gawugaa-gii-mara (head, heart, hands) form. The educator analysed student responses collected on the form, to prompt discussion in a series of four workshops. Students also completed the online 20-item Student Emotional Learning in Cultural Safety Education Instrument (SELCSI) which has two scales, Witnessing and Comfort. gawugaa-gii-mara responses were thematically coded. Paired sample t-tests examined differences over time. Eta squared determined effect size. RESULTS: There were 102 matched pre-post-intervention surveys. Both SELCSI scales had excellent internal consistency (Witnessing α = 0.80, Comfort α = 0.92). A statistically significant difference was observed between students' mean scores on the Witnessing scale prior to the course (M = 47.10, SD = 6.51) compared to post-course (53.04, SD = 4.80), t(95) = 8.70, p < 0.001 (two-tailed) with a large effect size (d = 0.88). Most Comfort scale items increased but were not statistically significant. Data from the gawugaa-gii-mara intervention (n = 162 written responses) revealed students were challenged by self-reflexivity. There was a disconnect between what students had learnt (gawugaa), what they had felt (gii) and how this would be applied in professional practice (mara). CONCLUSIONS: The First Peoples-led, emotions-based pedagogical intervention was brief, meaningful and effective. As students grappled with their emotional connection to self-reflexivity as well as their ability to translate new knowledge into culturally safe practice, these offer important avenues for future research.

A critique of measures of emotion and empathy in First Peoples' cultural safety in nursing education: A systematic literature review.

BACKGROUND: In Australia, undertaking cultural safety education often evokes strong emotional responses by health students. Despite the potential for emotion to drive transformative learning in this space, measures of emotion are uncommon. AIM: To review existing tools that intend to measure emotional components of learning in relation to cultural safety education. METHODS: Articles published in English from January 2005 to January 2020; reported studies from Australia, New Zealand, Canada and United States of America; and measured an emotional construct/s after an education intervention offered to university students enrolled in a health programme were included. Studies were assessed for quality according to the Critical Appraisals Skills Programme criteria. RESULTS: Eight articles were reviewed; five conducted in the United States of America, and three in Australia. Intervention type, measures, methodological rigour and outcomes varied. Studies predominately measured empathy, guilt and/or fear. CONCLUSIONS: Although students' emotional responses were measured, processes for students to reflect upon these reactions were not incorporated in the classroom. The review has implications for future research and curricula through developments in measuring and acting upon emotion in cultural safety education for nursing students in Australia.

Examining the transformative potential of emotion in education: A new measure of nursing and midwifery students' emotional learning in first peoples' cultural safety.

BACKGROUND: There is growing evidence that non-Indigenous health students engage with cultural safety content in complex emotional ways. Identifying those emotions may contribute to transformative learning. OBJECTIVES: To develop and test a measure of student emotion using an approach that centres relevant theory and First Peoples' perspectives, values and lived realities. DESIGN: This study used a descriptive, cohort design. PARTICIPANTS AND SETTING: All health professional students enrolled in an undergraduate Australian First Peoples health course (n = 616) were invited to complete an online survey. METHODS: A staged approach to tool development included: (1) item generation; (2) response selection; (3) expert review; (4) pilot testing, and (5) psychometric testing of the 20-item draft tool. Tests included item analysis, principal components analysis with varimax rotation, subscale analysis, and internal reliability. RESULTS: One hundred and nine surveys were analysed (17.7% response rate) predominantly from nursing and midwifery students (n = 96, 88.1%). Testing resulted in the development of the two-scaled Student Emotional Learning in Cultural Safety Instrument (SELCSI). The 12-item Witnessing scale revealed three factors explaining 62.17% of variance, and the 8-item Comfort scale had two factors explaining 67.62% of the variance. Cronbach's alpha showed good internal consistency (Witnessing scale α = 0.78; Comfort scale α = 0.88). There was a correlation between mean Witnessing (M = 50.06, SD 5.66) and Comfort (M = 32.44, SD 5.01) scores (r = 0.47, p < 0.001, 95% CI [0.304-0.643]). CONCLUSIONS: The two scales of students' emotional learning were found to have preliminary validity and reliability. Use of the tool has important theoretical, pedagogical and methodological considerations for cultural safety in nursing and midwifery education. This tool may contribute to understanding how nursing and midwifery students learn to practice in culturally safe ways.

Experiences and outcomes of health professional students undertaking education on Indigenous health: A systematic integrative literature review.

OBJECTIVES: To explore the experiences and outcomes of health professional students when undertaking education on Indigenous health. DESIGN: An integrative systematic literature review. DATA SOURCES: The search was undertaken from September 2017-November 2017. Six databases were searched: CINAHL, Scopus, Informit Health Collection, Informit Indigenous Collection, Proquest - Nursing and Allied Health Collection; and Proquest - Health and Medical Collection. Reference lists of all articles were scanned for further relevant articles. REVIEW METHODS: The search strategy was limited to English articles published in the previous decade. Articles were included if they focused on Indigenous health content provided to health professional university students, with a focus on Indigenous populations of Australia, New Zealand, Canada and the United States of America. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guided the review. Studies were evaluated for methodological rigour using the CASP rating checklist. Both qualitative and quantitative data were coded using thematic qualitative analysis methods and presented as a meta-aggregation. RESULTS: Twelve articles were included. Synthesis found significant variability in the ways Indigenous health issues were taught and integrated into health programs, particularly with regards to quality, methodological rigour of evaluation, pedagogical approaches and student experiences. Four themes were developed to describe student experiences and learning outcomes. These included: increasing knowledge of Indigenous health; emotional responses to content and teaching processes; perceived value of Indigenous health education; and cultural competence and critical thinking. CONCLUSIONS: Methodologically sound longitudinal studies are required to test if early changes in student knowledge and attitudes may be sustained. How students' 'increase in knowledge' translates to cultural capability is unclear, and there is a need for validated tools to measure this construct. A more sophisticated critique of how students emotionally engage with Indigenous health content, including understanding the relationships between 'discomfort' and transformative experiences is required.

Validation of the first peoples cultural capability measurement tool with undergraduate health students: A descriptive cohort study.

BACKGROUND: Health professional graduates require the capacity to work safely, both clinically and culturally, when delivering care to Indigenous peoples worldwide. In the Australian context, the Aboriginal and Torres Strait Islander Health Curriculum Framework (The Framework) provides guidance for health professional programs to integrate, teach and assess Aboriginal and Torres Strait Islander peoples' (First Peoples) health content. There is, however, a lack of validated tools that measure the development of students' cultural capabilities. OBJECTIVES: To validate the Cultural Capability Measurement Tool with a cohort of health professional students. DESIGN: A descriptive cohort design was used. SETTING AND PARTICIPANTS: All students (N = 753) enrolled in a discrete First Peoples Health course at an Australian university were invited to complete the Cultural Capability Measurement Tool. METHODS: The tool was tested for reliability, content and construct validity using confirmatory factor analysis; and concurrent validity using and the Cultural Understanding Self-Assessment Tool. RESULTS: A sample of 418 (73% response rate) was recruited. Most participants were enrolled in the Bachelor of Nursing program (n = 369, 82%). The Cultural Capability Measurement Tool had a Cronbach's alpha coefficient of 0.86. A five-factor solution was confirmed which reflected the cultural capability domains and accounted for 51% of the variance. Scores correlated with students' cultural understanding (r = 0.28, p < 0.001). CONCLUSIONS: Successful implementation of The Framework requires instruments to measure changes in students' cultural capabilities. Measuring nursing students' cultural capabilities can inform their development, identify areas of strengths and deficits for educators, and will ultimately contribute to the development of a culturally safe nursing workforce.

'Work it out': evaluation of a chronic condition self-management program for urban Aboriginal and Torres Strait Islander people, with or at risk of cardiovascular disease.

BACKGROUND: Chronic diseases disproportionately burden Aboriginal and Torres Strait Islander people in Australia, with cardiovascular (CV) diseases being the greatest contributor. To improve quality of life and life expectancy for people living with CV disease, secondary prevention strategies such as rehabilitation and self-management programs are critical. However, there is no published evidence examining the effect of chronic condition self-management (CCSM) group programs for Aboriginal and Torres Strait Islander people who have, or are at risk of, CV disease specifically. This study evaluates the Work It Out program for its effect on clinical outcome measures in urban Aboriginal and Torres Strait Islander participants with or at risk of CV disease. METHODS: This study was underpinned by a conceptual framework based on Aboriginal and Torres Strait Islander community control. Participants had at least one diagnosed CV disease, or at least one CV disease risk factor. Short-term changes in clinical outcome measures over (approximately) 12 weeks were evaluated with a quasi-experimental, pre-post test design, using paired t-tests. Factors contributing to positive changes were tested using general linear models. The outcome measures included blood pressure (mmHg), weight (kg), body mass index (kg/m2), waist and hip circumference (cm), waist to hip ratio (waist cm/hip cm) and six minute walk test (6MWT). RESULTS: Changes in several clinical outcome measures were detected, either within the entire group (n = 85) or within specific participant sub-groups. Participant's 6MWT distance improved by an average 0.053 km (95% CI: 0.01-0.07 km). The change in distance travelled was influenced by number of social and emotional wellbeing conditions participants presented with. The weight of participants classified with extreme obesity decreased on average by 1.6 kg (95% CI: 0.1-3.0 kg). Participants with high baseline systolic blood pressure demonstrated a mean decrease of 11 mmHg (95% CI: 3.2-18.8 mmHg). Change in blood pressure was influenced by the number of cardiovascular conditions participants experienced. CONCLUSIONS: Short-term improvements seen in some measures could indicate a trend for improvement in other indicators over the longer term. These results suggest the Work It Out program could be a useful model for cardiovascular rehabilitation and prevention for other urban Aboriginal and Torres Strait Islander populations.

Development of a First Peoples-led cultural capability measurement tool: A pilot study with midwifery students.

BACKGROUND: Midwives have a central role in closing the gap in health inequalities between Australias' First Peoples and other childbearing women. The Aboriginal and Torres Strait Islander Health Curriculum Framework (The Framework) identifies five core cultural capabilities (respect, communication, safety and quality, reflection and advocacy) to foster culturally safe health care. AIM: To use a decolonising, First Peoples-led approach to develop and validate a tool to measure the development students' cultural capabilities. METHOD: A pre- post intervention design was used. Development of the Cultural Capability Measurement Tool followed a staged process which centred on First Peoples' knowledges. This process included: item generation, expert review; a pilot, test-retest; and psychometric testing (reliability, factor analysis and construct validity). All third year midwifery students (n=49) enrolled in a discrete First Peoples health course were invited to complete the survey pre and post course. FINDINGS: A response rate of 77.5% (n=38/49) pre-course and 30.6% (15/49) at post-course was achieved. The tool demonstrated good internal reliability (Cronbach alpha=.89-.91). Principal component analysis with varimax rotation produced a five-factor solution. A paired samples t-test revealed a significant increase from pre-course (mean 93.13, SD 11.84) to post-course scores (mean=100.53, SD 7.54) (t (14)=-2.79, p=.014). CONCLUSION: A First Peoples approach was critical to tool development and conceptual validity. The 22 item Cultural Capability measurement Tool reflected the core cultural capabilities of The Framework. The draft tool appears suitable for use with midwifery students.

"Yarning" as a method for community-based health research with Indigenous women: the Indigenous Women's Wellness Research Program.

This project explores yarning as a methodology for understanding health and wellness from an indigenous woman's perspective. Previous research exploring indigenous Australian women's perspectives have used traditional Western methodologies and have often been felt by the women themselves to be inappropriate and ineffective in gathering information and promoting discussion. This research arose from the indigenous women themselves, and resulted in the exploration of using yarning as a methodology. Yarning is a conversational process that involves the sharing of stories and the development of knowledge. It prioritizes indigenous ways of communicating, in that it is culturally prescribed, cooperative, and respectful. The authors identify different types of yarning that are relevant throughout their research, and explain two types of yarning-family yarning and cross-cultural yarning-which have not been previously identified in research literature. This project found that yarning as a research method is appropriate for community-based health research with indigenous Australian women. This may be an important finding for health professionals and researchers to consider when working and researching with indigenous women from other countries.