Using codesign to develop a culturally tailored, behavior change mHealth intervention for indigenous and other priority communities: A case study in New Zealand.

The obesity rate in New Zealand is one of the highest worldwide (31%), with highest rates among Maori (47%) and Pasifika (67%). Codesign was used to develop a culturally tailored, behavior change mHealth intervention for Maori and Pasifika in New Zealand. The purpose of this article is to provide an overview of the codesign methods and processes and describe how these were used to inform and build a theory-driven approach to the selection of behavioral determinants and change techniques. The codesign approach in this study was based on a partnership between Maori and Pasifika partners and an academic research team. This involved working with communities on opportunity identification, elucidation of needs and desires, knowledge generation, envisaging the mHealth tool, and prototype testing. Models of Maori and Pasifika holistic well-being and health promotion were the basis for identifying key content modules and were applied to relevant determinants of behavior change and theoretically based behavior change techniques from the Theoretical Domains Framework and Behavior Change Taxonomy, respectively. Three key content modules were identified: physical activity, family/whanau [extended family], and healthy eating. Other important themes included mental well-being/stress, connecting, motivation/support, and health literacy. Relevant behavioral determinants were selected, and 17 change techniques were mapped to these determinants. Community partners established that a smartphone app was the optimal vehicle for the intervention. Both Maori and Pasifika versions of the app were developed to ensure features and functionalities were culturally tailored and appealing to users. Codesign enabled and empowered users to tailor the intervention to their cultural needs. By using codesign and applying both ethnic-specific and Western theoretical frameworks of health and behavior change, the mHealth intervention is both evidence based and culturally tailored.

Boosting efficacy of nurse-led stop smoking interventions with a quit and win contest: pilot study results.

BACKGROUND: Grave disparities in smoking prevalence exist between indigenous Maori, Pacific Island peoples, and other New Zealanders. Primary care nurses routinely provide brief stop smoking interventions to achieve national targets but they are constrained by time. Innovations using new technologies offer opportunities to enhance brief interventions and improve uptake and outcomes. Objectives/Aims/Hypotheses: This study explored the feasibility of adding a novel scratch card and internet-based, quit and win contest with mobile phone support messages, to practice nurses' brief smoking cessation interventions. DESIGN: Pragmatic exploratory mixed methods pilot study comprising a quantitative two-group comparison and qualitative interviews. METHODS: In two intervention clinics, practice nurses added supportive mobile phone messages, novelty scratch cards to win online prizes and $1000 prize draw entry following 1 month smokefree, to routine brief stop smoking interventions. In three control clinics, patients who smoked received brief stop smoking interventions only. Practice nurses collected baseline and 1-month data describing patients' smoking status, quit attempts, and cessation support. Researchers conducted qualitative interviews with two nurses and ten patients and collected 3-month data. RESULTS: Five primary care clinics recruited 67 smokers (37 intervention; 30 control). The contest was readily incorporated into nurses' practice. It appealed to nurses and Maori and Pacific Island patients, increased time to first cigarette, and attracted first time quitters. However, it had no extra effect on smoking cessation compared with usual care. Pacific Island patients' participation in the online elements was limited by low access to the internet. CONCLUSIONS: While the exploratory study did not indicate the potential for triggering mass quitting, reduced dependency was suggested. The intervention attracted Maori and Pacific Island smokers and engaged first time quitters. Low cost, novelty activities could be used to refresh routine brief stop smoking interventions, and to motivate practice nurses to engage more smokers in quitting.

O jovem e a educação indígena Tremembé de Almofala no Ceará / The young and the Tremembé of Almofala indigenous education in Ceará / El jóven y la educación indígena Tremembé de Almofala en Ceará

O presente artigo objetiva narrar a experiência da comunidade Indígena Tremembé, na constituição da educação na Escola Maria Venância, assim como o surgimento do Magistério Indígena Tremembé (Emit), e do Magistério Indígena Tremembé Superior (Mits), levando em consideração a participação dos jovens indígenas daquela comunidade na implementação dessa educação. A pesquisa, de natureza qualitativa, teve como técnica principal a observação participante, optando-se pela realização de entrevistas, registros no diário de campo, rodas de conversas e participação em eventos nas comunidades indígenas. A compreensão dos fatos se deu a partir das percepções dos próprios indígenas, pois eles fizeram parte desse processo de modo direto e ativo. Incluem-se, nas análises aqui empreendidas, as contribuições de estudiosos como Grabner (2006), Alarcão (2008), Grupioni (2001), bem como as leituras de documentos oficiais como o Parecer 14/99 (CNE, 1999), entre outros, e, sobretudo, as falas e análises dos jovens da aldeia sobre como eles percebem a relevância da conquista da educação indígena Tremembé.

The present article objectives to narrate the experience of the Tremembé Indigenous Community, in the education's constitution at the School Maria Venância, as the emergence of the Tremembé Indigenous Mastership (Emit), and of the Superior Tremembé Indigenous Mastership (Mits), taking into consideration the participation of the young indigenous of that community in the implementation of this education. The research, of qualitative nature, had as main technic the participative observation, choosing for the realization of interviews, registers in the field diary, conversation wheels and the participation in events in the indigenous communities. The comprehension of the facts it was made by the perceptions of the indigenous themselves, because those made part of this process in a direct and active way. It includes, in the reviews here undertaken, the contributions of scholars as Grabner (2006), Alarcão (2008), Grupioni (2001), as the reading of the officials documents as Parecer 14/99 (CNE, 1999), among others, and, above all, the speaks and analysis of the young in the village about how they perceived the relevance of the conquest of the Tremembé indigenous education.

El presente artículo objetiva narrar la experiencia de la comunidad indígena Tremembé, en la constitución de la educación en la Escuela Maria Venância, así como el surgimiento del Magisterio Indígena Tremembé (Emit), y del Magistério Indígena Tremembé Superior (Mits), teniendo en cuenta la participación de los jóvenes indígenas de aquella comunidad en el implemento de esa educación. La pesquisa, de naturaleza cualitativa, tuvo como técnica principal la observación participante, eligiéndose por la realización de entrevistas, registros en el diario de campo, ruedas de charlas y participación en eventos en las comunidades indígenas. La comprensión de los factos se dio a partir de las percepciones de los propios indígenas, pues estos hacían parte del proceso de manera directa y activa. Incluyese, en los análisis acá emprendidos, las contribuciones de estudiosos como Grabner (2006), Alarcão (2008) Grupioni( (2001), así como de lecturas de documentos oficiales como lo Parecer 14/99 (CNE, 1999), entre otros, y, especialmente, las palabras y análisis de los jóvenes de la aldea sobre como ellos perciben la relevancia de la conquista de la educación indígena Tremembé.

Reshaping Policies to Achieve a Strategic Plan for Indigenous Engagement in Nursing Education.

Canadian universities are developing strategies to address the Truth and Reconciliation Commission (TRC) Calls to Action. There has been much attention paid to the positivist, individualistic and Eurocentric foundations of nursing and its educational curricula, but limited focus on assessing organizational structures or engaging with stakeholders. Without both approaches, the success of new initiatives may be limited. The College of Nursing at the University of Saskatchewan implemented a "Learn Where You Live" model that demonstrated a sense of place by providing access and opportunity in rural, remote and northern regions of the province. Key to this initiative was the creation of the position of Strategist for Outreach and Indigenous Engagement, whose role it is to develop strategic initiatives designed to interpret and influence socio-political and policy-level system changes. This paper shares how adding a political scientist to nursing education created an interprofessional team by introducing new ways of thinking and being that have cultural relevance and understanding for a sustainable future.

Insufficient evidence on health literacy amongst Indigenous people with cancer: a systematic literature review.

BACKGROUND: Indigenous people experience poorer cancer survival outcomes compared with non-Indigenous people. Currently, there is growing awareness of poor health literacy as a determinant of cancer outcomes. However, little attention has been given to researching cancer-related health literacy amongst Indigenous people. OBJECTIVES: To systematically review empirical studies of cancer health literacy amongst Indigenous people worldwide. METHODS: Articles were identified in Medline (1946-2013); Pre-Medline; CINAHL; PsycINFO (1967-2013); PubMed; Current Contents/All Editions (1993-2013); Allied Health and Complimentary Medicine (1985-2013), and in the reference lists of retrieved articles and by expert consultation. 64 abstracts were screened for inclusion and 16 articles were retained. RESULTS: There is a paucity of high-quality research concerning of health literacy amongst Indigenous cancer patients. No articles used formal measures of health literacy and data on the prevalence of health literacy was not reported. Of the 7 articles describing interventions only one included a control group and the remainder employed quasi-experimental methods. CONCLUSIONS: Research is needed to explore the cultural relevance of existing measures of health literacy and to document the prevalence of health literacy amongst Indigenous people with cancer. A better understanding of Indigenous cancer patients' health literacy is required before health literacy interventions can be designed to improve Indigenous cancer outcomes.

Development and Use of Health-Related Technologies in Indigenous Communities: Critical Review.

BACKGROUND: Older Indigenous adults encounter multiple challenges as their age intersects with health inequities. Research suggests that a majority of older Indigenous adults prefer to age in place, and they will need culturally safe assistive technologies to do so. OBJECTIVE: The aim of this critical review was to examine literature concerning use, adaptation, and development of assistive technologies for health purposes by Indigenous peoples. METHODS: Working within Indigenous research methodologies and from a decolonizing approach, searches of peer-reviewed academic and gray literature dated to February 2016 were conducted using keywords related to assistive technology and Indigenous peoples. Sources were reviewed and coded thematically. RESULTS: Of the 34 sources captured, only 2 concerned technology specifically for older Indigenous adults. Studies detailing technology with Indigenous populations of all ages originated primarily from Canada (n=12), Australia (n=10), and the United States (n=9) and were coded to four themes: meaningful user involvement and community-based processes in development, the digital divide, Indigenous innovation in technology, and health technology needs as holistic and interdependent. CONCLUSIONS: A key finding is the necessity of meaningful user involvement in technology development, especially in communities struggling with the digital divide. In spite of, or perhaps because of this divide, Indigenous communities are enthusiastically adapting mobile technologies to suit their needs in creative, culturally specific ways. This enthusiasm and creativity, coupled with the extensive experience many Indigenous communities have with telehealth technologies, presents opportunity for meaningful, culturally safe development processes.

The impact of culturally responsive self-management interventions on health outcomes for minority populations: A systematic review.

OBJECTIVES: The health of people from Indigenous and ethnic minorities is poorer than the remainder of the population. Frequently, Westernized health systems respond by introducing self-management interventions to improve chronic illness health outcomes. The aim of this study was to answer the research question: "Can self-management programs that have been adapted or modified still be effective for ethnic minority and Indigenous populations?" METHODS: A systematic review across four databases was conducted. RESULTS: Twenty-three publications met the inclusion criteria. As the studies were heterogeneous, meta-analysis was not possible. Overall, interventions resulted in more positive health outcomes than usual care, but findings were inconsistent. DISCUSSION: We argue that rather than focusing on individual skills, knowledge, self-efficacy, and attitudes toward self-management, it may be more important to explore the structures and processes that underpin the sharing of information and skills within clinical or education encounters. Given that self-management is a Western cultural construct, creating empathic and responsive systems might be more effective for improving health of Indigenous and ethnic minority groups rather than relying predominantly on individual skill development.

THE COGNITIVE COMPETENCES OF IMMIGRANT AND NATIVE STUDENTS ACROSS THE WORLD: AN ANALYSIS OF GAPS, POSSIBLE CAUSES AND IMPACT.

Immigration, immigration policies and education of immigrants alter competence levels. This study analysed their effects using PISA, TIMSS and PIRLS data (1995 to 2012, N=93 nations) for natives' and immigrants' competences, competence gaps and their population proportions. The mean gap is equivalent to 4.71 IQ points. There are large differences across countries in these gaps ranging from around +12 to -10 IQ points. Migrants' proportions grow roughly 4% per decade. The largest immigrant-based 'brain gains' are observed for Arabian oil-based economies, and the largest 'brain losses' for Central Europe. Regarding causes of native-immigrant gaps, language problems do not seem to explain them. However, English-speaking countries show an advantage. Acculturation within one generation and intermarriage usually reduce native-immigrant gaps (≅1 IQ point). National educational quality reduces gaps, especially school enrolment at a young age, the use of tests and school autonomy. A one standard deviation increase in school quality represents a closing of around 1 IQ point in the native-immigrant gap. A new Greenwich IQ estimation based on UK natives' cognitive ability mean is recommended. An analysis of the first adult OECD study PIAAC revealed that larger proportions of immigrants among adults reduce average competence levels and positive Flynn effects. The effects on economic development and suggestions for immigration and educational policy are discussed.

A tertiary approach to improving equity in health: quantitative analysis of the Maori and Pacific Admission Scheme (MAPAS) process, 2008-2012.

INTRODUCTION: Achieving health equity for indigenous and ethnic minority populations requires the development of an ethnically diverse health workforce. This study explores a tertiary admission programme targeting Maori and Pacific applicants to nursing, pharmacy and health sciences (a precursor to medicine) at the University of Auckland (UoA), Aotearoa New Zealand (NZ). Application of cognitive and non-cognitive selection tools, including a Multiple Mini Interview (MMI), are examined. METHODS: Indigenous Kaupapa Maori methodology guided analysis of the Maori and Pacific Admission Scheme (MAPAS) for the years 2008-2012. Multiple logistic regression models were used to identify the predicted effect of admission variables on the final MAPAS recommendation of best starting point for success in health professional study i.e. 'CertHSc' (Certificate in Health Sciences, bridging/foundation), 'Bachelor' (degree-level) or 'Not FMHS' (Faculty of Medical and Health Sciences). Regression analyses controlled for interview year, gender and ancestry. RESULTS: Of the 918 MAPAS interviewees: 35% (319) were Maori, 58% (530) Pacific, 7% (68) Maori/Pacific; 71% (653) school leavers; 72% (662) females. The average rank score was 167/320, 40-80 credits below guaranteed FMHS degree offers. Just under half of all interviewees were recommended 'CertHSc' 47% (428), 13% (117) 'Bachelor' and 38% (332) 'Not FMHS' as the best starting point. Strong associations were identified between Bachelor recommendation and exposure to Any 2 Sciences (OR:7.897, CI:3.855-16.175; p < 0.0001), higher rank score (OR:1.043, CI:1.034-1.052; p < 0.0001) and higher scores on MAPAS mathematics test (OR:1.043, CI:1.028-1.059; p < 0.0001). MMI stations had mixed associations, with academic preparation and career aspirations more consistently associated with recommendations. CONCLUSIONS: Our findings raise concerns about the ability of the secondary education sector to prepare Maori and Pacific students adequately for health professional study. A comprehensive tertiary admissions process using multiple tools for selection (cognitive and non-cognitive) and the provision of alternative entry pathways are recommended for indigenous and ethnic minority health workforce development. The application of the MMI within an equity and indigenous cultural context can support a holistic assessment of an applicant's potential to succeed within tertiary study. The new MAPAS admissions process may provide an exemplar for other tertiary institutions looking to widen participation via equity-targeted admission processes.

Learning by Observing and Pitching In and the Connections to Native and Indigenous Knowledge Systems.

This chapter opens a broader dialogue of Learning by Observing and Pitching-In (LOPI) with Native and Indigenous Studies, and Native and Indigenous Education, drawing particular attention to how LOPI can provide a model for better understanding Indigenous pedagogy in Indigenous Knowledge Systems (IKS). As Battiste (2002) pointed out, "Indigenous pedagogy values a person's ability to learn independently by observing, listening, participating with a minimum of intervention and instruction." Like LOPI, IKS include ways of knowing and ways of being in the world, with life-long processes and responsibilities that model competent and respectful behavior. The chapter explores similarities and differences between IKS and LOPI by analyzing each perspective's scope, defining features, and foundational origins, as well as what each contributes to our understanding of Native and Indigenous communities, especially in terms of learning and incorporation into adulthood and family and community life.

Taima (stop) TB: the impact of a multifaceted TB awareness and door-to-door campaign in residential areas of high risk for TB in Iqaluit, Nunavut.

BACKGROUND: The incidence rate of active tuberculosis (TB) disease in the Canadian Territory of Nunavut has shown a rising trend over the past 10 years. In 2010 it was 60 times greater than the national incidence rate. The objective of the Taima (translates to "stop" in Inuktitut) TB study was to implement and evaluate a public health campaign to enhance existing TB prevention efforts in Nunavut. METHODS: A TB awareness campaign followed by a door-to-door screening campaign was carried out in Iqaluit, Nunavut. The aim of the campaign was to raise awareness about TB, and to provide in-home screening and treatment for people living in residential areas at high risk for TB. Screening was based on geographic location rather than on individual risk factors. RESULTS: During the general awareness campaign an increase in the number of people who requested TB testing at the local public health clinic was observed. However, this increase was not sustained following cessation of the awareness campaign. Targeted TB screening in high risk residential areas in Iqaluit resulted in 224 individuals having TSTs read, and detection of 42 previously unidentified cases of latent TB, (overall yield of 18.8% or number needed to screen = 5.3). These cases of latent TB infection (LTBI) were extra cases that had not been picked up by traditional screening practices (34% relative increase within the community). This resulted in a 33% relative increase in the completion of LTBI treatment within the community. The program directly and indirectly identified 5/17 new cases of active TB disease in Iqaluit during the study period (29.5% of all incident cases). CONCLUSIONS: While contact tracing investigations remain a cornerstone of TB prevention, additional awareness, screening, and treatment programs like Taima TB may contribute to the successful control of TB in Aboriginal communities.

Ngati and healthy: translating diabetes prevention evidence into community action.

INTRODUCTION: Type 2 diabetes mellitus (T2DM) is a major health issue in New Zealand Maori. Clinical trials have demonstrated potential for the prevention of T2DM, but whether community public health programmes aiming to prevent diabetes are effective is untested. OBJECTIVE: To describe the planning and design of an intervention aiming to translate T2DM prevention clinical trial evidence into a community-wide population health intervention in a high risk predominantly Maori community. APPROACH: Community concerns about the diabetes burden were heard by the local diabetes nurse, herself a tribal member, and discussed with a locally raised academic. Project planning ensued. The intervention and its evaluation were designed using a participatory community development model. The planned intervention had three components: community-wide health promotion initiatives conveying healthy lifestyle messages, community education and monitoring for identified high-risk individuals and their extended families, and a structural strategy aimed at adapting local environments to support lifestyle changes. The evaluation plan involved interrupted time series surveys coupled with formative and process evaluations rather than a randomised control trial design. DISCUSSION: Consulting communities, validating community concerns and prioritising cultural and ethical issues were key steps. Time spent developing good relationships amongst the health provider and academic research team members at the outset proved invaluable, as the team were united in addressing the project planning and implementation challenges, such as funding obstacles that arose because of our ethically and culturally appropriate non-randomised control trial evaluation design. The pre-intervention survey demonstrated high rates of diabetes (13%), insulin resistance (33%) and risk factors, and provided evidence for positive, as opposed to negative, lifestyle intervention messages. CONCLUSION: Community-wide lifestyle interventions have the potential to reduce rates of type 2 diabetes and other chronic diseases in high-risk communities, but require a high level of commitment from the health sector and buy-in from the community. Adequate commitment, leadership, planning and resources are essential.

Sexual minorities, human rights and public health strategies in Africa.

Remarkable progress has been made towards the recognition of sexual minority rights in Africa. At the same time, a marked increase in attacks, rhetorical abuse, and restrictive legislation against sexual minorities or 'homosexuality' makes activism for sexual rights a risky endeavour in many African countries. Campaigns for sexual rights and 'coming out' are frequently perceived as a form of Western cultural imperialism, leading to an exportation of Western gay identities and provoking a patriotic defensiveness. Cultures of quiet acceptance of same-sex relationships or secretive bisexuality are meanwhile also problematic given the high rate of HIV prevalence on much of the continent. This article examines specific initiatives that are using subtle, somewhat covert means to negotiate a path between rights activism and secretive bisexuality. It argues that strategies primarily focused on health concerns that simultaneously yet discreetly promote sexual rights are having some success in challenging prevalent homophobic or 'silencing' cultures and discourses.

Fat, desire and disgust in the colonial imagination.

This article tracks the relatively unexamined ways in which ethnographic, travel and medical knowledge interrelated in the construction of fat stereotypes in the nineteenth century, often plotted along a temporal curve from 'primitive' corpulence to 'civilized' moderation. By showing how the complementary insights of medicine and ethnography circulated in beauty manuals, weight-loss guides and popular ethnographic books ­ all of which were aimed at middle-class readers and thus crystallize certain bourgeois attitudes of the time ­ it argues that the pronounced denigration of fat that emerged in Britain and France by the early twentieth century acquired some of its edge through this ongoing tendency to depict desire for and acceptance of fat as fundamentally 'savage' or 'uncivilized' traits. This tension between fat and 'civilization' was by no means univocal or stable. Rather, this analysis shows, a complex and wide-ranging series of similarities and differences, identifications and refusals can be traced between British and French perceptions of their own bodies and desires and the shortcomings they saw in foreign cultures. It sheds light as well on those aspects of their own societies that seemed 'primitive' in ways that bore an uncomfortable similarity to the colonial peoples they governed, demonstrating how a gendered, yet ultimately unstable, double standard was sustained for much of the nineteenth century. Finally it reveals a subtle and persistent racial subtext to the anti-fat discourses that would become more aggressive in the twentieth century and which are ubiquitous today.

Skin lighteners, Black consumers and Jewish entrepreneurs in South Africa.

This article considers the rise and decline of South Africa's lucrative and controversial skin-lighteners market through examination of the business history of the largest manufacturers, Abraham and Solomon Krok, and their evolving personas as millionaires and philanthropists. Such examination reveals how the country's skin-lighteners trade emerged as part of the broader growth of a black consumer market after the Second World War and how elements of that market became the target of anti-apartheid protests in subsequent decades. It also demonstrates how the Kroks' experiences as second-generation Jewish immigrants shaped their involvement in the trade and how, later, their self-identification as Jewish philanthropists informed their efforts to rehabilitate their reputations following South Africa's 1990 ban on all skin lighteners. Such efforts include the building of Johannesburg's highly acclaimed Apartheid Museum, modelled after the United States Holocaust Memorial Museum. This article explores the profound ironies that some South Africans see in the fact that a museum dedicated to commemorating those who suffered under and, ultimately, triumphed against state racism was financed by a family fortune generated through the sale of skin lighteners to black consumers.

A demographic explanation for the recent rise in European fertility.

Between 1998 and 2008 European countries experienced the first continent-wide increase in the period total fertility rate (TFR) since the 1960s. After discussing period and cohort influences on fertility trends, we examine the role of tempo distortions of period fertility and different methods for removing them. We highlight the usefulness of a new indicator: the tempo- and parity-adjusted total fertility rate (TFRp*). This variant of the adjusted total fertility rate proposed by Bongaarts and Feeney also controls for the parity composition of the female population and provides more stable values than the indicators proposed in the past. Finally, we estimate levels and trends in tempo and parity distribution distortions in selected countries in Europe. Our analysis of period and cohort fertility indicators in the Czech Republic, Netherlands, Spain, and Sweden shows that the new adjusted measure gives a remarkable fit with the completed fertility of women in prime childbearing years in a given period, which suggests that it provides an accurate adjustment for tempo and parity composition distortions. Using an expanded dataset for ten countries, we demonstrate that adjusted fertility as measured by TFRp* remained nearly stable since the late 1990s. This finding implies that the recent upturns in the period TFR in Europe are largely explained by a decline in the pace of fertility postponement. Other tempo-adjusted fertility indicators have not indicated such a large role for the diminishing tempo effect in these TFR upturns. As countries proceed through their postponement transitions, tempo effects will decline further and eventually disappear, thus putting continued upward pressure on period fertility. However, such an upward trend may be obscured for a few years by the effects of economic recession.

Instant noodles as an antifriction device: making the BOP with PPP in PNG.

Focusing primarily, but not exclusively, on urban and periurban Papua New Guinea (PNG), we discuss the significance of instant ramen noodles to those now known as the "bottom of the pyramid" (BOP). Although instant noodles are remarkable in that they are eaten by virtually everyone in the world, albeit in different amounts and for different reasons, they are marketed in PNG specifically as a "popularly positioned product" (PPP) for the BOP. Cheap, convenient, tasty, filling, and shelf stable, they are a modern addition to Sidney Mintz's classic "proletarian hunger killers" of sugar, tea, and coffee. But, we argue, instant noodles have a distinctive contemporary role: they do more than sustain the poor; they transform them into the aspiring consumers of the BOP. As such, instant noodles can be viewed as an antifriction device, greasing the skids of capitalism as it extends its reach.