Psychometric validation of the Growth and Empowerment Measure (GEM) applied with Indigenous Australians

Measuring empowerment in pregnant women: A scoping review of progress in instruments

BACKGROUND

The empowerment of pregnant women is a meaningful strategy that profoundly impacts the health of women and their children. Despite a significant increase in the empowerment of pregnant women and its measurement, little attention was given to a consensus on the selection and application of assessment instruments used for pregnant women.

OBJECTIVE

To identify the available assessment instruments for measuring the empowerment of pregnant women and to describe the appraisal content and their psychometric properties.

METHODS

We searched nine bibliographic databases for original studies that focus on the measurement of empowerment in pregnant women. Arksey and O'Malley's methodology and PRISMA-ScR were selected to guide the implementation of this scoping review. The COSMIN criteria was employed to assess the methodological quality and the quality of psychometric properties.

RESULTS

A total of 23 studies were included and 13 instruments were extracted. Given comprehensive considerations, Kameda's prenatal empowerment scale may be deemed suitable. The included instruments comprehensively measured the attributes of empowerment, with a particular focus on facilitating women's choice and decision-making. Except for the four most recent self-designed questionnaires, the remaining instruments had been tested for reliability and/or validity.

CONCLUSION

There were heterogeneous results regarding the included instruments' appraisal content and psychometric properties. Future studies focusing on the development or validation of measurement instruments should be guided by influential and identical standards.

Human immunodeficiency virus prevention outcomes associated with arts-based sexual health workshop participation among Northern and Indigenous adolescents in the Northwest Territories, Canada

BACKGROUND

Contextually tailored, arts-based HIV prevention strategies hold potential to advance adolescent sexual health and wellbeing. We examined HIV prevention outcomes associated with arts-based sexual health workshop participation with Northern and Indigenous adolescents in the Northwest Territories (NWT), Canada.

METHODS

An Indigenous community-based youth agency delivered arts-based workshops in school settings to adolescents aged 13-18 in 24 NWT communities. Pre and post-test surveys included socio-demographic characteristics, sexually infections (STI) knowledge, HIV/STI risk perception, sexual relationship equity, condom use self-efficacy, and safer sex efficacy (SSE). Latent change score models were conducted to assess pre-post differences and factors associated with these differences.

RESULTS

Among participants (n = 344; mean age 14.3 years, SD: 1.3; Indigenous: 79%) most (66%) had previously attended this workshop. Latent change score models revealed a significant and large effect size for increased STI knowledge (β = 2.10, SE = 0.48, p < .001) and significant and small effect sizes for increased HIV/STI risk perception (β = 0.24, SE = 0.06, p < .001) and SSE (β = 0.16, SE = 0.07, p = .02). The largest increases across several outcomes occurred with first time workshop participants; yet previous workshop participants continued to report increases in HIV/STI risk perception and SSE.

CONCLUSION

Arts-based HIV prevention approaches show promise in advancing STI knowledge, risk perception, and SSE with Northern and Indigenous youth.

Development of the What Matters 2 Adults (WM2A) wellbeing measure for Aboriginal and Torres Strait Islander adults

PURPOSE

As wellbeing is culturally bound, wellbeing measures for Aboriginal and Torres Strait Islander peoples must be culturally relevant and grounded in Aboriginal and Torres Strait Islander values and preferences. We describe the development of a nationally-relevant and culturally grounded wellbeing measure for Aboriginal and Torres Strait Islander adults: the What Matters to Adults (WM2A) measure.

METHODS

We used a mixed methods approach to measure development, combining Indigenist methodologies and psychometric methods. Candidate items were derived through a large national qualitative study. Think-aloud interviews (n = 17) were conducted to assess comprehension, acceptability, and wording of candidate items. Two national surveys collected data on the item pool (n = 312, n = 354). Items were analysed using exploratory factor analysis (EFA), and item response theory (IRT) to test dimensionality, local dependence and item fit. A Collaborative Yarning approach ensured Aboriginal and Torres Strait Islander voices were privileged throughout.

RESULTS

Fifty candidate items were developed, refined, and tested. Using EFA, an eight factor model was developed. All items met pre-specified thresholds for maximum endorsement frequencies, and floor and ceiling effects; no item redundancy was identified. Ten items did not meet thresholds for aggregate adjacent endorsement frequencies. During Collaborative Yarning, six items were removed based on low factor loadings (<0.4) and twelve due to conceptual overlap, high correlations with other items, endorsement frequencies, and/or low IRT item level information. Several items were retained for content validity. The final measure includes 32 items across 10 domains (Balance & control; Hope & resilience; Caring for others; Culture & Country; Spirit & identity; Feeling valued; Connection with others; Access; Racism & worries; Pride & strength).

CONCLUSIONS

The unique combination of Indigenist and psychometric methodologies to develop WM2A ensures a culturally and psychometrically robust measure, relevant across a range of settings and applications.

Pathways: A guide for developing culturally safe and appropriate patient-reported outcome (PROMs) and experience measures (PREMs) with Indigenous peoples

BACKGROUND

Members of the Indigenous Health Program, BC Children's and Women's Hospitals and the University of British Columbia embarked on a joint project to describe best practices to support the creation of patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) with Indigenous peoples.

METHODS

The project involved a review of previous research on patient-reported measures (surveys) that had been specifically developed for Indigenous populations. It also involved interviews with key stakeholders-Indigenous and non-Indigenous academic researchers, and Indigenous community leaders and community members. Themes from the interviews and the literature review were combined and synthesized into pathways/a framework for survey development.

RESULTS

The pathways document consisted of 13 protocols and associated teachings for guiding processes and framing survey questions. These encompassed building relationships, community engagement and consultation, benefits to community, ceremony and storytelling, two-way learning, participatory content development, governance and accountability. Findings emphasized the criticality of Indigenous leadership in setting priorities for PROMs and PREMS and establishing relationships that honour Indigenous experiences through all phases of a study. Assessment of the framework's validity with select research participants and the Project Advisory Committee was positive.

CONCLUSION

This is the first framework to guide development of PROMs and PREMs with Indigenous peoples and communities. It addresess both process and outcome and includes concrete steps that collaborators can take when establishing a partnership that is respectful and inclusive of Indigenous ways of knowing and being.

Development of an Aboriginal Resilience and Recovery Questionnaire - a collaboration between practitioners and help-seeking clients of a Victorian Aboriginal community controlled health service

BACKGROUND

Indigenous experiences and perspectives of resilience, healing and recovery from trauma is gaining increasing attention, with a growing qualitative literature that spans multiple indigenous cultural groups. However, few quantitative measures are available. In this article, development of a preliminary version of the Aboriginal Resilience and Recovery Questionnaire is described.

AIM

The first aim of this study was to describe findings from two focus groups that provided theoretical knowledge and development of items for a draft version of an Aboriginal Resilience Recovery Questionnaire. The second aim of the study was to conduct a preliminary psychometric analysis of the properties of the measure.

DESIGN

Multi-method research design grounded in indigenous research methodologies.

MEASURES

Aboriginal Resilience and Recovery Questionnaire, Australian Aboriginal Version of the Harvard Trauma Questionnaire Trauma symptom subscale, Growth and Empowerment Measure.

RESULTS

(1) Two focus groups with six counselling staff from an Aboriginal health service were run that explored Victorian Aboriginal understandings of resilience, healing, and recovery from trauma. Sixty different protective factors viewed as potentially important to resilience, healing and recovery from trauma were identified by participants. (2) Following a review of the resilience literature, 75 items were reviewed and revised, with additional items developed by the focus group. (3) The final outcome was 60 items selected for a preliminary version of the Aboriginal Resilience Recovery Questionnaire, 50 of which made up 19 different subscales in addition to 10 single items. (4) Structured interviews were conducted with 81 help seeking Aboriginal clients recruited from the same health service. Preliminary psychometric assessment of the Aboriginal Resilience Recovery Questionnaire was undertaken using Principal Components Analysis. Two component subscales were extracted with adequate internal consistency and good convergent and discriminant validity. For both subscales there were moderate to strong positive associations with empowerment, and moderate to strong negative associations with trauma symptom severity.

CONCLUSION

The preliminary results are promising for a strength-based resilience measure developed from the knowledge of Aboriginal practitioners and staff of a counselling service. Further research to address some psychometric limitations in the measure is required. A larger sample size will allow for a common factor analysis to be conducted. The Aboriginal Resilience Recovery Questionnaire has potential to assist Aboriginal Community Controlled Health Organisations and other organisations to evaluate whether services and programs can effectively support community members to strengthen individual, relational, community and cultural resilience resources.

The methods of improving cultural sensitivity of depression scales for use among global indigenous populations: a systematic scoping review

Cultural adaptation of psychometric measures has become a process aimed at increasing acceptance, reliability, and validity among specific Indigenous populations. We present a systematic scoping review to: (1) identify the depression scales that have been culturally adapted for use among Indigenous populations worldwide, (2) globally report on the methods used in the cultural adaptation of those scales, and (3) describe the main features of those cultural adaptation methods. We included articles published from inception to April 2021, including 3 levels of search terms: Psychometrics, Indigenous, and Depression. The search was carried out in the Ovid Medline, PubMed, Embase, Global Health, PsycINFO, and CINAHL databases, following PRISMA guidelines. We identified 34 reports on processes of cultural adaptation that met the criteria. The scales were adapted for use among Indigenous populations from Africa, Australia, Asia, North America, and Latin America. The most common scales that underwent adaptation were the Patient Health Questionnaire (PHQ-9), the Center for Epidemiologic Studies Depression Scale (CES-D), and the Edinburgh Postnatal Depression Scale (EPDS). Methods of adaptation involved a revision of the measures' cultural appropriateness, standard/transcultural translation, revision of the administration process, and inclusion of visual supports. Culturally safe administration of scales was reported in some studies. To come to a consensus on most appropriate methods of improving cultural safety of psychometric measurement, most studies utilized qualitative methods or mixed methods to understand the specific community's needs. Revision of linguistic equivalence and cultural relevance of content, culturally safe administration procedures, qualitative methods, and participatory research were key features of developing safe culturally adapted measures for depressive symptoms among Indigenous populations. While for comparability, uniform scales would be ideal as mental health evaluations, an understanding of the cultural impact of measurements and local depression expressions would benefit the process of developing culturally sensitive psychometric scales. PROSPERO registration ID: CRD42023391439.

"This has changed me to be a better mum": A qualitative study exploring how the Australian Nurse-Family Partnership Program contributes to the development of First Nations women's self-efficacy

BACKGROUND

The Australian Nurse-Family Partnership Program is based on the Nurse-Family Partnership program from the United States, which was designed to support first-time mothers experiencing social and economic disadvantage from early in pregnancy until their child's second birthday. International trials have demonstrated this program measurably improves family environment, maternal competencies, and child development. The Australian program has been tailored for mothers having a First Nations baby.

AIM

This study aimed to understand how the program impacts self-efficacy using a qualitative interpretive approach.

METHODS

The study took place in two sites within one Aboriginal Community Controlled Health Service in Meanjin (Brisbane), Australia. Twenty-nine participants were interviewed: first-time mothers having a First Nations baby who had accessed the program (n = 26), their family members (n = 1), and First Nations Elders (n = 2). Interviews were conducted either face-to-face or by telephone, using a yarning tool and method, to explore women's experiences and perceptions. Yarns were analysed using reflexive thematic analysis.

FINDINGS

Three main themes were generated: 1) sustaining connections and relationships; 2) developing self-belief and personal skills; and 3) achieving transformation and growth. We interpret that when the program facilitates the development of culturally safe relationships with staff and peers, it enables behaviour change, skill development, personal goal setting and achievement, leading to self-efficacy.

DISCUSSION

Located within a community-controlled health service, the program can foster cultural connection, peer support and access to health and social services; all contributing to self-efficacy.

CONCLUSION

We recommend the program indicators are strengthened to reflect these findings and enable monitoring and reporting of activities that facilitate self-efficacy, growth, and empowerment.

Our Ways, Your Ways, Both Ways - a multi-disciplinary collaboration to develop, embed and evaluate a model of social and emotional wellbeing care for Aboriginal and Torres Strait Islander young people who experience detention - Phase 1

The National Strategic Framework for Aboriginal and Torres Strait Islander Peoples' Mental Health and Social and Emotional Wellbeing identifies building a strong Aboriginal and Torres Strait Islander led evidence-base to inform care as a key priority. Aboriginal and/or Torres Strait Islander adolescents in contact with the criminal justice system are a highly vulnerable group of Australians, with substantial unmet needs. There is limited evidence to inform culturally appropriate models of care that meet the social and emotional wellbeing needs of justice-involved Aboriginal and/or Torres Strait Islander adolescents. This project aims to develop, implement and evaluate an in-reach and community transitional model of social and emotional wellbeing care for Aboriginal and/or Torres Strait Islander adolescents (10-17 years old) who experience detention through close engagement with Aboriginal and/or Torres Strait Islander youth, Elders, researchers, practitioners and community members, and by drawing on culturally informed practice and knowledge systems. The project is based on a multi-level mixed methods design, with a strong focus on ongoing project evaluation (based on the Ngaa-bi-nya framework) and co-design. Co-design is facilitated through culturally safe and trauma informed participatory processes based on development of strong partnerships from project initiative, design, implementation and evaluation. Application of the landscape domain of the Ngaa-bi-nya framework for Aboriginal and Torres Strait Islander program evaluation will be explored in Phase one. Aboriginal and Torres Strait Islander adolescents with experience in detention will be engaged through one-on-one interviews with data collection through the Growth and Empowerment Measure (GEM) Youth (which will be adapted from the adult version and validated as part of this study), the Kessler Psychological Distress Scale (K-10), questions around alcohol and drug use, and narrative interviews exploring experience. Qualitative data will be analyzed using an inductive thematic approach, structured within the framework of the Ngaa-bi-nya landscape prompts. Quantitative data will be analyzed using descriptive statistics to provide a profile of the cohort. Findings from Phase one will be used to inform the development of a model of social and emotional wellbeing care that will be implemented and evaluated in Phase two.

Safe and valid? A systematic review of the psychometric properties of culturally adapted depression scales for use among Indigenous populations

Background

Implementing culturally sensitive psychometric measures of depression may be an effective strategy to improve acceptance, response rate, and reliability of psychological assessment among Indigenous populations. However, the psychometric properties of depression scales after cultural adaptation remain unclear.

Methods

We screened the Ovid Medline, PubMed, Embase, Global Health, PsycInfo, and CINAHL databases through three levels of search terms: Depression, Psychometrics, and Indigenous, following the PRISMA guidelines. We assessed metrics for reliability (including Cronbach's alpha), validity (including fit indices), and clinical utility (including predictive value).

Results

Across 31 studies included the review, 13 different depression scales were adapted through language or content modification. Sample populations included Indigenous from the Americas, Asia, Africa, and Oceania. Most cultural adaptations had strong psychometric properties; however, few and inconsistent properties were reported. Where available, alphas, inter-rater and test-retest reliability, construct validity, and incremental validity often indicated increased cultural sensitivity of adapted scales. There were mixed results for clinical utility, criterion validity, cross-cultural validity, sensitivity, specificity, area under the receiver operating characteristic curve, predictive value, and likelihood ratio.

Conclusions

Modifications to increase cultural relevance have the potential to improve fit and acceptance of a scale by the Indigenous population, however, these changes may decrease specificity and negative predictive value. There is an urgent need for suitable tools that are useful and reliable for identifying Indigenous individuals for clinical treatment of depression. This awaits future work for optimal specificity and validated cut-off points that take into account the high prevalence of depression in these populations.

Approaches to the development of new screening tools that assess distress in Indigenous peoples: A systematic mixed studies review

This mixed studies review assessed the extent of the literature related to approaches used to develop new tools that screen for distress in Indigenous adults globally. It answered the research question: What qualitative and quantitative approaches are used to develop new screening tools that assess distress in Indigenous peoples globally? CINAHL, Embase, Emcare, Medline, PsychInfo and Scopus databases were systematically searched to identify relevant articles published between January 2000 and February 2023. Articles describing the development of a new screening tool for Indigenous peoples, globally, published in English since 2000 and constituted a full publication of primary research, met the inclusion criteria. Studies underwent quality appraisal using the Mixed-Methods Appraisal Tool. A sequential exploratory design guided data analysis. Synthesis occurred using a two-phase sequential method. Nineteen articles constituted the data set. Articles described the use of qualitative, quantitative, or mixed methods in approximately equal numbers. Overall, qualitative methods were used in early stages of tool development, with mixed and quantitative methods used to pilot and validate them. However, most studies did not follow the theoretical guidelines for tool development, and while validation studies took place in over half of the data set, none adequately assessed construct validity. Sixty percent of the articles were located using citation searches, which suggests database searches were ineffective. Valid tools that screen for distress in Indigenous populations support equitable access to health care. This review found that most screening tools were developed in Australia. However, additional evidence of their validity is needed in addition to a valid diagnostic tool that supports the determination of criterion validity. These needs present important future research opportunities.

Enabling dads and improving First Nations adolescent mental health: a pragmatic randomised controlled study

INTRODUCTION

There are few empirically supported social and emotional well-being programmes for First Nations adolescents, and we found none targeting those living in Aboriginal communities in remote areas of Australia. The dearth of social and emotional well-being programmes is concerning given that adolescents in remote Australia are at much greater risk of mental disorder and suicide. Our pragmatic community-based research intervention 'Enabling Dads and Improving First Nations Adolescent Mental Health' is designed by and for First Nations people living in remote communities to promote and support the parenting role and examine the interconnection between men's parenting knowledge and adolescent mental health. The aim is to improve adolescent mental health by strengthening the participating father's empowerment, parenting confidence and engagement in the parenting role. The words Aboriginal, First Nation and Indigenous are applied interchangeably, as appropriate, throughout the article.

METHODS AND ANALYSIS

The intervention is currently being conducted in five remote First Nations communities in Far North Queensland, Australia. The project is funded by the Medical Research Future (MRFF UNSW RG200484), and staff recruitment and training began in early December 2020. The aim is to recruit 100 men and dyad adolescents, that is, in each of the five community sites, we will recruit 20 men and adolescent dyads at baseline. To date, we have complete data collection in one community, and fieldwork will begin in the final community in September 2023.The intervention involves a pragmatic randomised controlled trial, using a novel and culturally designed and manualised parenting programme with men (Strong Fathers, SF). The comparison group is receiving a culturally congruent and familiar yarning/relaxation (YR) condition. The SF component focuses on reinforcing knowledge related to parenting adolescents, promoting father's empowerment, and increasing their confidence and engagement with the adolescent. The second component systematically measures and examines differences in adolescent social and emotional well-being before and after their father's involvement in either the SF or YR. The adolescent is blind to the father's group allocation. The outcome measures for the men include parenting knowledge, attitudes and beliefs; a First Nations measure for empowerment; the Harvard Trauma Questionnaire (Indigenous) used to assess post-traumatic stress disorder symptoms; and alcohol use. The adolescent mental health outcomes are measured by a culturally congruent social and emotional well-being measure.

ETHICS AND DISSEMINATION

Ethics approval was granted from the Aboriginal Health and Medical Research Council of Australia: Human Research Ethics Committee (1711/20). Results will be verbally shared at community meetings and conferences, and reports will be produced for community stakeholder use. Data will be available for community-controlled health services and stakeholders. Findings will also be published in peer-reviewed journals, and summaries will be provided to the funders of the study as well as male participants and adolescents.

Partnering with Aboriginal and Torres Strait Islander Peoples: An Evaluation Study Protocol to Strengthen a Comprehensive Multi-Scale Evaluation Framework for Participatory Systems Modelling through Indigenous Paradigms and Methodologies

The social and emotional wellbeing of young Aboriginal and Torres Strait Islander peoples should be supported through an Indigenous-led and community empowering approach. Applying systems thinking via participatory approaches is aligned with Aboriginal and Torres Strait Islander research paradigms and can be an effective method to deliver a decision support tool for mental health systems planning for Indigenous communities. Evaluations are necessary to understand the effectiveness and value of such methods, uncover protective and healing factors of social and emotional wellbeing, as well as to promote Aboriginal and Torres Strait Islander self-determination over allocation of funding and resources. This paper presents modifications to a published evaluation protocol for participatory systems modelling to align with critical Aboriginal and Torres Strait Islander guidelines and recommendations to support the social and emotional wellbeing of young people. This paper also presents a culturally relevant participatory systems modelling evaluation framework. Recognizing the reciprocity, strengths, and expertise Aboriginal and Torres Strait Islander methodologies can offer to broader research and evaluation practices, the amended framework presented in this paper facilitates empowering evaluation practices that should be adopted when working with Aboriginal and Torres Strait Islander peoples as well as when working with other diverse, non-Indigenous communities.

How Australian First Nations peoples living in the Torres Strait and Northern Peninsula Area of Australia describe and discuss social and emotional well-being: a qualitative study protocol

INTRODUCTION

Colonisation has, and continues to, negatively impact the mental well-being of Australia's First Nations peoples. However, the true magnitude of the impact is not known, partially because clinicians have low levels of confidence in using many existing screening tools with First Nations clients. In addition, many authors have critiqued the use of tools designed for Western populations with First Nations peoples, because their worldview of health and well-being is different. Therefore, the aim of the overarching study is to develop an appropriate mental well-being screening tool(s) for older adults (aged 45 and over) living in the Torres Strait that can be used across primary health and geriatric settings. This protocol describes the first phase designed to achieve the overarching aim-yarning about social and emotional well-being (inclusive of mental well-being) in First Nations peoples living in the Torres Strait and Northern Peninsula Area of Australia.

METHOD AND ANALYSIS

The study will be guided by decolonising and participatory action research methodologies. Yarning is an Australian First Nations relational method that relies on storytelling as a way of sharing knowledge. Yarning circles will be conducted with community members and health and aged care workers living on six different island communities of the Torres Strait. Participants will be recruited using purposive sampling. Thematic analysis of the data will be led by Torres Strait Islander members of the research team.

ETHICS AND DISSEMINATION

The Far North Queensland, Human Research Ethics Committee (HREC) (HREC/2021/QCH/73 638-1518) and James Cook University HREC (H8606) have approved this study. Dissemination of study findings will be led by Torres Strait members of the research team through conferences and peer-reviewed publications.

"Every day I grew stronger and stronger being there".: empowerment through land-and art-based Peer Leader retreats with Indigenous and Northern young people

Indigenous adolescents in Canada are among those shouldering the impacts of colonialism and racism. Peer approaches and art-and-land-based programming have demonstrated promise to support empowerment and well-being, yet little is known about their efficacy with Northern and Indigenous adolescents in Canada or of how this group conceptualises empowerment. Fostering Open eXpression among Youth (FOXY) and Strength, Masculinities, and Sexual Health (SMASH) conduct land-and-arts-based Peer Leader Retreats with adolescents from the Northwest Territories, Nunavut and the Yukon Territories. Retreats (2017–2019) included 286 participants (n=196 women [trans-inclusive], n=84 men [trans-inclusive], n=5 non-binary), aged 12–19, the majority of whom (n=235) were Indigenous. Participants completed surveys immediately before and following retreats and 6 months after. Focus group discussions (FGDs) (n=24) were conducted with participants (peer leaders and apprentices) (n=232) following the retreat, and youth staff members (peer facilitators) (aged 14–21, n=7 FGDs). Applying thematic analysis, we explored retreat experiences (FGDs), and Wilcoxon signed-rank tests to examine pre/post retreat changes in leadership, empowerment, and self-confidence (surveys). Quantitatively, there were statistically significant increases in leadership and empowerment in post-retreat scores compared to pre-retreat. Qualitatively, findings demonstrate how Peer Leader Retreats premised on land-and-art-based approaches can support empowerment, confidence, leadership, and social-connectedness.

Co‐creation of a student‐implemented allied health service in a First Nations remote community of East Arnhem Land, Australia

OBJECTIVES

To co-create a culturally responsive student-implemented allied health service in a First Nations remote community and to determine the feasibility and acceptability of the service.

DESIGN

Co-creation involved a pragmatic iterative process, based on participatory action research approaches. Feasibility and acceptability were determined using a mixed-method pre/postdesign.

SETTING

The service was in Nhulunbuy, Yirrkala and surrounding remote First Nations communities of East Arnhem Land, Northern Territory, Australia.

PARTICIPANTS

Co-creation of the service was facilitated by the Northern Australia Research Network, guided by Indigenous Allied Health Australia leadership, with East Arnhem local community organisations and community members. Co-creation of the day-to-day service model involved local cultural consultants, service users and their families, staff of community organisations, students, supervisors, placement coordinators and a site administrator.

FINDINGS

A reciprocal learning service model was co-created in which culturally responsive practice was embedded. The service was feasible and acceptable: it was delivered as intended; resources were adequate; the service management system was workable; and the service was acceptable. Health outcome measures, however, were not appropriate to demonstrate impact, particularly through the lens of the people of East Arnhem. Recommendations for the service included: continuing the reciprocal learning service model in the long term; expanding to include all age groups; and connecting with visiting and community-based services.

CONCLUSION

The co-created service was feasible and acceptable. To demonstrate the impact of the service, measures of health service impact that are important to First Nations people living in remote communities of northern Australia are required.

Cultural adaptation of an appropriate tool for mental health among Kanien'kehá:ka: a participatory action project based on the Growth and Empowerment Measure

We present a cultural adaptation of the Growth and Empowerment Measure (GEM) from the Kanien'kehá:ka people of Quebec (Canada). Our aim was to develop a culturally competent and safe tool to assess and promote well-being among this population. We followed a qualitative, collaborative, and participatory method that sought to benefit Indigenous participants and communities, while honouring their culture and philosophies. Twelve adults from health and community services of Kahnawà:ke participated in total five focus group meetings. We carried out a thematic analysis of the data collected through an advisory group that led a revision of the cultural and conceptual relevance of the tool and its content. The group integrated socio-culturally relevant elements and restructured the tool so that it reflected local well-being factors and showed its versatility of being an assessment tool and therapeutic support. A narrative and empowerement-driven approach, culturally based intervention, cultural safety and flexibility when using the instrument were considered successful strategies to improve wellness. This project provides valuable information about the perspectives of local Indigenous communities regarding mental health and factors of empowerment. Mutual understanding and integration of psychological and traditional knowledge can create a beneficial program to improve emotional, mental, spiritual, and physical well-being for the local population. It remains to be tested whether the Kanien'kehá:ka Growth and Empowerment Measure (K-GEM) is clinically useful in psychological and psychiatric intervention, and social and community services.

Strengthening assessment and response to mental health needs for Aboriginal and Torres Strait Islander children and adolescents in primary care settings: study protocol for the Ngalaiya Boorai Gabara Budbut implementation project

INTRODUCTION

Opportunities for improved mental health and wellbeing of Aboriginal and Torres Strait Islander children and young people lie in improving the capability of primary healthcare services to identify mental healthcare needs and respond in timely and appropriate ways. The development of culturally appropriate mental health assessment tools and clinical pathways have been identified as opportunities for strengthening workforce capacity in this area. The Ngalaiya Boorai Gabara Budbut implementation project seeks to pursue these opportunities by developing and validating a psychosocial assessment tool, understanding what services need to better care for your people and developing resources that address those needs.

METHODS AND ANALYSIS

The project will be governed by a research governance group comprising Aboriginal service providers, young people, and researchers. It will be implemented in an urban health service in Canberra, and regional services in Moree, Wollongong, and the Illawarra regions of New South Wales Australia. The validation study will follow an argument-based approach, assessing cultural appropriateness and ease of use; test-retest validity; internal consistency, construct validity and the quality of decisions made based on the assessment. Following piloting with a small group of young people and their caregivers (n=10), participants (n=200) will be young people and/or their caregivers, attending one of the partner services. The needs assessment will involve an in-depth exploration of service via an online survey (n=60) and in-depth interviews with service providers (n=16) and young people (n=16). These activities will run concurrently. Service providers, researchers and the governance group will codesign resources that respond to the needs identified and pilot them through the participating services.

ETHICS AND DISSEMINATION

The Aboriginal Health and Medical Research Council of NSW Human Research Ethics committee (#1769/21) has approved this project. Informed consent will be obtained from all participants and/or their caregivers (with assent from those aged <16 years) prior to participating in all aspects of the study. Research dissemination will occur through participating health services, academic journal articles and conference presentations.

Using the Stay Strong App for the Well-being of Indigenous Australian Prisoners: Feasibility Study

Background

The gap between mental health needs and resources for Aboriginal and Torres Strait Islander people, the Indigenous people of Australia, is most marked in the prison population. Indigenous people are overrepresented in Australian prisons. In prison, this group experiences mental disorders to a greater degree than non-Indigenous prisoners. This group has also been found to experience mental disorder at a higher rate than Indigenous people in the community. In addition to pre-existing determinants of poor mental health, these high prevalence rates may reflect poor engagement in mainstream interventions or the efficacy of available interventions. In community populations, the use of digital mental health resources may help to increase access to well-being support. However, culturally appropriate digital tools have not been available to Indigenous people in prisons. The absence of feasibility and efficacy studies of these tools needs to be addressed.

Objective

The aim of this study is to determine the feasibility of the Stay Strong app as a digital well-being and mental health tool for use by Indigenous people in prison.

Methods

Dual government agency (health and corrective services) precondition requirements of implementation were identified and resolved. This was essential given that the Stay Strong app was to be delivered by an external health agency to Indigenous prisoners. Then, acceptability at a practice level was tested using postuse qualitative interviews with clients and practitioners of the Indigenous Mental Health Intervention Program. All Indigenous Mental Health Intervention Program practitioners (10/37, 27%) and client participants who had completed their second follow-up (review of the Stay Strong app; 27/37, 73%) during the study period were invited to participate.

Results

Owing to the innovative nature of this project, identifying and resolving the precondition requirements of implementation was challenging but provided support for the implementation of the app in practice. Acceptability of the app by clients and practitioners at a practice level was demonstrated, with nine themes emerging across the interviews: satisfaction with the current Stay Strong app, supported client goal setting, increased client self-insight, improved client empowerment, cultural appropriateness, enhanced engagement, ease of use, problems with using an Android emulator, and recommendations to improve personalization.

Conclusions

The Stay Strong Custody Project is a pioneering example of digital mental health tools being implemented within Australian prisons. Using the app within high-security prison settings was found to be feasible at both strategic and practice levels. Feedback from both clients and practitioners supported the use of the app as a culturally safe digital mental health and well-being tool for Aboriginal and Torres Strait Islander people in prison.

A Web-Based Alcohol and Other Drug Prevention Program (Strong & Deadly Futures) for Aboriginal and Torres Strait Islander School Students: Protocol for a Cluster Randomized Controlled Trial

Background

There are no available school-based alcohol and drug prevention programs with evidence of effectiveness among Aboriginal and Torres Strait Islander youth. To address this, we codeveloped the Strong & Deadly Futures well-being and alcohol and drug prevention program in partnership with an Indigenous creative design agency and 4 Australian schools.

Objective

This paper presents the protocol to evaluate the effectiveness of Strong & Deadly Futures in reducing alcohol and other drug use and improving well-being among Aboriginal and Torres Strait Islander youth.

Methods

The target sample will be 960 year 7 and 8 students from 24 secondary schools in Australia, of which approximately 40% (384/960) will identify as Aboriginal or Torres Strait Islander. The study design is a 2-group, parallel cluster randomized controlled trial with allocation concealment. Recruited schools will be block randomized (ratio 1:1), stratified by geographical remoteness, by an independent statistician. Schools will be randomized to receive Strong & Deadly Futures, a web-based alcohol and drug prevention and social and emotional well-being program that delivers curriculum-aligned content over 6 lessons via an illustrated story, or health education as usual (control). Control schools will be supported to implement Strong & Deadly Futures following trial completion. Surveys will be administered at baseline, 6 weeks, 12 months, and 24 months (primary end point) post baseline. Primary outcomes are alcohol use (adapted from the National Drug Strategy Household Survey), tobacco use (Standard High School Youth Risk Behavior Survey), and psychological distress (Kessler-5 Psychological Distress Scale). Secondary outcomes are alcohol and drug knowledge and intentions, alcohol-related harms, binge drinking, cannabis use, well-being, empowerment, appreciation of cultural diversity, and truancy.

Results

The trial was funded by the National Health and Medical Research Council in January 2019, approved by the Human Research Ethics Committee of the University of Sydney (2020/039, April 2020), the Aboriginal Health and Medical Research Council of New South Wales (1620/19, February 2020), the Western Australian Aboriginal Health Ethics Committee (998, October 2021), and the ethics committees of each participating school, including the New South Wales Department of Education (2020170, June 2020), Catholic Education Western Australia (RP2020/39, November 2020), and the Queensland Department of Education (550/27/2390, August 2021). Projected dates of data collection are 2022-2024, and we expect to publish the results in 2025. A total of 24 schools have been recruited as of submission of the manuscript.

Conclusions

This will be the first cluster randomized controlled trial of a culturally inclusive, school-based alcohol and drug prevention program for Aboriginal and Torres Strait Islander youth; therefore, it has significant potential to address alcohol and other drug harms among Aboriginal and Torres Strait Islander youth.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12620001038987; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380038&isReview=true

International Registered Report Identifier (IRRID)

PRR1-10.2196/34530

Empowerment Approaches in Childhood Weight Management: A Systematic Review

Empowerment interventions facilitate individuals, organizations, and communities to gain better control over their health. They are distinctly different from traditional behavior change models and encourage participants to set their own health priorities and agenda. Current evidence suggests empowerment interventions are efficacious for smoking, sexual, and mental health outcomes. However, empowerment in childhood obesity (which remains a global public health challenge) is underresearched. This review systematically analyzed the evidence for empowerment approaches in childhood weight management. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. A search strategy was applied to six databases from inception to May 25, 2021. Evidence was appraised using The Academy of Nutrition and Dietetics Quality Criteria Checklist and National Health and Medical Research Council Levels of Evidence. Of the 9274 articles identified, 29 articles describing 14 programs met the inclusion criteria. Twenty-five studies rated positive and four rated neutral. Overall, the evidence body rated "B." Seventy-two percent of the 3318 participants were from priority populations, highlighting the unique ability of empowerment interventions to engage those most in need. Results demonstrate small to large improvements in participant body mass index with effect sizes ranging from 0.08 to 1.13. Throughout the literature, empowerment was measured inconsistently and usually with a surrogate marker. All studies were set in America or Canada. This review suggests empowerment should be further investigated in childhood weight management. Empowerment interventions represent a unique opportunity to meaningfully integrate self-determination to clinical childhood weight management practice and overcome current barriers related to priority population engagement.

Assessment tools measuring health-related empowerment in psychosocially vulnerable populations: a systematic review

BACKGROUND

Many programs are undertaken to facilitate the empowerment of vulnerable populations across the world. However, an overview of appropriate empowerment measurements to evaluate such initiatives remains incomplete to date. This systematic review aims to describe and summarise psychometric properties, feasibility and clinical utility of the available tools for measuring empowerment in psychosocially vulnerable populations.

METHODS

A systematic literature review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was completed. A descriptive approach was used for data analysis. Papers were eligible if they explored the development, validation, cross-cultural translation or the utility of an empowerment measurement tool in the context of psychosocially vulnerable populations.

RESULTS

Twenty-six included articles described twenty-six separate studies in which 16 empowerment measurement tools were developed, validated/translated, or used. There was heterogeneity in empowerment constructs, samples targeted, and psychometric properties measured. The measurement of reliability of the included instruments was satisfactory in most cases. However, the validity, responsiveness, interpretability, feasibility and clinical utility of the identified measurement tools were often not adequately described or measured.

CONCLUSION

This systematic review provides a useful snapshot of the strengths as well as limitations of existing health related empowerment measurement tools used with psychosocially vulnerable populations in terms of their measurement properties, and constructs captured. It highlights significant gaps in empowerment tool measurement, development and evaluation processes. In particular, the results suggest that in addition to systematic assessments of psychometric properties, the inclusion of feasibility and clinical utility as outcome measures are important to assess relevance to clinical practice.

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.

Depression or resilience? A participatory study to identify an appropriate assessment tool with Kanien'kéha (Mohawk) and Inuit in Quebec

PURPOSE

We present a study on selection of a psychometric scale to be clinically used among Indigenous people with depression. Our aim was to select a psychometric tool for cultural adaptation with Mohawk and Inuit in Quebec.

METHODS

We selected three depression scales and three protective factor scales based on: strong validity for psychometric properties, evidence for good psychometric qualities across translations, avoidance of cognitively complex sentences, brevity, and clarity. We submitted the scales for consultation, and followed qualitative participatory methods with Mohawks of Kahnawake and Inuit from Nunavik living in an urban environment. We collected data through ten focus groups with advisory committees, and carried out a thematic analysis of the information.

RESULTS

The advisory groups considered the measurement scales to be unsafe. The major components that hindered their acceptance were: numeric rating, self-evaluation (versus supportive interaction), and a focus on symptoms rather than supportive factors. The participants preferred the Growth and Empowerment Measure due to its empowering approach. They voiced that it is necessary to develop a culturally sensitive and safe tool which facilitates interactions between the person and the practitioner.

CONCLUSION

This project provides valuable information about the perspectives of local Indigenous peoples regarding mental health and factors of empowerment and resilience. The ideal tool should be flexible in terms of the content and its use as compared to the conventional psychometric strategies. A tool developed with the Indigenous perspective on wellbeing could be used in psychological and psychiatric intervention as well as in social and community services.

Australian Aboriginal and Torres Strait Islander Health Information: Progress, Pitfalls, and Prospects

Despite significant developments in Aboriginal and Torres Strait Islander Health information over the last 25 years, many challenges remain. There are still uncertainties about the accuracy of estimates of the summary measure of life expectancy, and methods to estimate changes in life expectancy over time are unreliable because of changing patterns of identification. Far too little use is made of the wealth of information that is available, and formal systems for systematically using that information are often vestigial to non-existent. Available information has focussed largely on traditional biomedical topics and too little on access to, expenditure on, and availability of services required to improve health outcomes, and on the underpinning issues of social and emotional wellbeing. It is of concern that statistical artefacts may have been misrepresented as indicating real progress in key health indices. Challenges and opportunities for the future include improving the accuracy of estimation of life expectancy, provision of community level data, information on the availability and effectiveness of health services, measurement of the underpinning issues of racism, culture and social and emotional wellbeing (SEWB), enhancing the interoperability of data systems, and capacity building and mechanisms for Indigenous data governance. There is little point in having information unless it is used, and formal mechanisms for making full use of information in a proper policy/planning cycle are urgently required.

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.

Ngaa-bi-nya-nhumi-nya (to Test First): Piloting the Feasibility of Using the Growth and Empowerment Measure with Aboriginal Pregnant Women Who Smoke

Introduction

Aboriginal pregnant women who smoke experience barriers to quitting, including challenges to social and emotional well-being, but these are infrequently quantified. Finding an appropriate measurement tool in this setting is crucial to increase knowledge for holistic smoking cessation interventions.

Aims

To pilot the Growth and Empowerment Measure (GEM) with a sample of pregnant Aboriginal women who smoke.

Methods

Aboriginal women participating in the step-wedge ICAN QUIT in Pregnancy pilot study completed the GEM comprised of 14-item Emotional Empowerment Scale (EES14), 12 Scenarios (12S), and K6 items at baseline, 4 weeks, and 12 weeks. Qualitative interviews with service staff were held at the end of the study to assess feasibility.

Results

15 pregnant Aboriginal women took part between November 2016 and July 2017. At 12 weeks, n = 8/12 (67%) of women reported an increase in both the EES14 and 12S scores. Total 12S scores were significantly higher at 12 weeks (p = 0.0186). Total K6 had a nonsignificant trend for reduction (p = 0.0547). Staff reported that the length of the survey presents challenges in this setting.

Conclusions

A shortened, modified GEM is recommended in this setting. We recommend the GEM to be tested in a larger study, powered to assess its associations with smoking behaviours.

Identifying risk and protective factors, including culture and identity, for methamphetamine use in Aboriginal and Torres Strait Islander communities: Relevance of the 'communities that care' model

BACKGROUND AND AIMS

There is a need for more evidence to guide efforts to address harmful methamphetamine use amongst young Aboriginal and Torres Strait Islander Australians. 'Communities that Care' (CTC) is an evidence-based process developed to prevent alcohol and other drug-related harm but its suitability for use in Aboriginal contexts has not been established. This study sought to explore whether risk and protective factors for methamphetamine use, as described by Aboriginal stakeholders, align with the CTC risk and protective factor framework.

METHOD

Focus groups and individual interviews were conducted in Aboriginal communities nationally. Data were analysed thematically using the CTC framework as a deductive coding framework. Additional themes were captured and summarised.

RESULTS

Participants were 147 (80% Aboriginal; 44% female) key stakeholders aged between 16 and 69 (median=40), recruited via organisational and community networks in each site. Relevant factors were identified in all four CTC domains: community, family, school, peer/individual. However, these four domains did not capture issues of central importance to Aboriginal people. These were summarised as an additional domain, 'Culture and Identity.'

CONCLUSIONS

Given that the Communities that Care risk and protective framework did not sufficiently capture issues of central importance to Aboriginal people, there is a need for different, community-informed models that reflect the unique determinants of use in this context.

Why validation is not enough: Setting the scene for the implementation of the Kimberley Mum's Mood Scale

Background

The two part Kimberley Mum’s Mood Scale (KMMS) has been developed and validated as a culturally appropriate perinatal depression and anxiety screening tool for Aboriginal women living in the sparsely populated Kimberley region of North West Australia. As part of implementation aspects of user acceptability were explored to improve clinical utilisation of the KMMS.

Methods

Eighteen health professionals involved in perinatal care participated in an online survey or a qualitative semi-structured interview. Ten Aboriginal women (who held administrative, professional or executive roles) were subsequently interviewed in depth to further explore aspects of KMMS user acceptability.

Results

Many of the health professionals were not using the second part of the KMMS (the psychosocial discussion tool). Time constraints and a perception that the KMMS is only appropriate for women with literacy issues were identified by health professionals as significant barriers to KMMS uptake. In contrast the Aboriginal women interviewed considered the KMMS to be important for literate Aboriginal women and placed high value on having the time and space to ‘yarn’ with health professionals about issues that are important to them.

Conclusion

Implementing the KMMS across the Kimberley region requires health professionals to be trained. It also requires strategic engagement with health services to ensure health professionals and mangers understand the rationale and significance of the KMMS and are engaged in its successful implementation.

WOmen's Action for Mums and Bubs (WOMB) Trial Protocol: A Non-randomized Stepped Wedge Implementation Trial of Participatory Women's Groups to Improve the Health of Aboriginal and Torres Strait Islander Mothers and Children in Australia

Introduction: In Australia, there have been improvements in Aboriginal and Torres Strait Islander maternal health, however inequities remain. There is increasing international evidence illustrating the effectiveness of Participatory Women's Groups (PWGs) in improving Maternal and Child Health (MCH) outcomes. Using a non-randomized, cluster stepped-wedge implementation of a complex intervention with mixed methods evaluation, this study aims to test the effectiveness of PWGs in improving MCH within Indigenous primary care settings in Australia and how they operate in various contexts. Methods: This study takes place in ten primary health care services across Australia and involves the recruitment of existing PWGs or the setting up of new PWGs. Services are paired based on geography for practical reasons and two services commence the PWG intervention at three monthly intervals, with the initial four services being those with existing women's groups. Implementation of the PWGs as an intervention involves training local facilitators of PWG groups, supported engagement with local MCH data through workshops, PWGs identifying and prioritizing issues and strengths and co-implementing solutions with health services. Outcomes are measured with yearly MCH audits, a cost-effectiveness study, and process evaluation of community participation and empowerment. Discussion: This study is the first to formally implement and quantitatively, yet with contextual awareness, measure the effect of applying a community participation intervention to improve the quality of Aboriginal and Torres Strait Islander MCH in Australia. Findings from this work, including detailed theory-producing qualitative analysis, will produce new knowledge of how to facilitate improved quality of MCH care in Indigenous PHC settings and how to best engage community in driving health care improvements. Trial registration: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12618000945224. Web address: http://www.ANZCTR.org.au/ACTRN12618000945224.aspx.

Integrating Healthcare Services for Indigenous Australian Students at Boarding Schools: A Mixed-Methods Sequential Explanatory Study

INTRODUCTION

Many Aboriginal and Torres Strait Islander Australian adolescents from remote communities attend boarding schools, requiring integrated healthcare between home and schools. This study explored students' health status, healthcare service use and satisfaction.

METHODOLOGY

A two-phased mixed-methods explanatory design was implemented. 32 Indigenous primary and 188 secondary boarding school students were asked their health status, psychological distress, use of healthcare services in community and boarding school, and service satisfaction. Results were fed back to students, parents and community members, and education and healthcare staff to elicit further explanation and interpretation.

RESULTS

In the previous year, 75% of primary and 81% of secondary boarding school students had visited a doctor. More than 90% were satisfied with healthcare services used. Despite 27.1% reporting high psychological distress, students did not perceive distress as reducing their overall health, nor was distress associated with mental healthcare service use.

DISCUSSION

Despite high levels of service use and satisfaction, this study highlighted the need for improved healthcare integration for Indigenous adolescents between school-based and remote community services. Further research is needed to identify students' expectations and models for healthcare integration.

CONCLUSION

With resourcing, schools could play a greater role in facilitating access to healthcare.

An exploratory study of culture in treatment for Aboriginal Australian men in residential drug and alcohol rehabilitation services

The objectives of the research are to describe the cultural activities offered in residential drug and alcohol rehabilitation for Aboriginal Australian men, along with client perceptions of the benefits associated with these cultural activities. Participants were 101 Australian Aboriginal male clients attending five residential drug and alcohol rehabilitation services in New South Wales. Participants completed a semi-structured interview and questionnaires that included the Growth and Empowerment Measure, the Aboriginal Cultural Engagement Survey, Clinical Global Impressions, and two questionnaires regarding cultural engagement while in treatment. Service users indicated that the most beneficial cultural activities offered within services were traditional art/craft, culturally-focused talks/meetings, and being on the land. Hierarchical multiple regression analysis indicated that cultural engagement in everyday life significantly predicted empowerment but not other measures of mental ill-health. The opinions of service users are presented, and recommendations are made regarding ways to enhance the effectiveness of cultural activities within drug and alcohol rehabilitation programs.

Comparing enhanced versus standard Diabetes Prevention Program among indigenous adults in an urban setting: a randomized controlled trial

Background

Indigenous people in the United States are at high risk for diabetes. Psychosocial stressors like historical trauma may impede success in diabetes prevention programs.

Methods

A comparative effectiveness trial compared a culturally tailored diabetes prevention program (standard group) with an enhanced one that addressed psychosocial stressors (enhanced group) in 2015 to 2017. Participants were 207 Indigenous adults with a body mass index (BMI) of ≥30 and one additional criterion of metabolic syndrome, and were randomized to the standard or enhanced group. Both groups received a culturally tailored behavioral diabetes prevention program. Strategies to address psychosocial stressors were provided to the enhanced group only. Change in BMI over 12 months was the primary outcome. Secondary outcomes included change in quality of life, and clinical, behavioral, and psychosocial measures at 6 and 12 months.

Results

The two groups did not significantly differ in BMI change at 12 months. The two groups also did not differ in any secondary outcomes at 6 or 12 months, with the exception of unhealthy food consumption; the standard group reported a larger mean decrease (95% CI) in consumption of unhealthy food compared with the enhanced group (− 4.6 [− 6.8, − 2.5] vs. -0.7 [− 2.9, 1.4], p = 0.01). At 6 months, significant improvements in weight and the physical component of the quality of life measure were observed for both groups compared with their baseline level. Compared with baseline, at 12 months, the standard group showed significant improvement in BMI (mean [95% CI], − 0.5 [− 1.0, − 0.1]) and the enhanced group showed significant improvement in the physical component of the quality of life (2.9 [0.7, 5.2]).

Conclusions

Adding strategies to address psychosocial barriers to a culturally tailored diabetes prevention program was not successful for improving weight loss among urban Indigenous adults.

Trial Registration

(if applicable): NCT02266576. Registered October 17, 2014 on clinicaltrials.gov. The trial was prospectively registered.

Adapting the psychological mediation framework for cisgender and transgender sexual minorities in Jamaica: Implications from latent versus observed variable approaches to sexual stigma

RATIONALE

Sexual minorities' mental health disparities are produced in larger contexts of sexual stigma. There is limited understanding of pathways between sexual stigma dimensions (e.g., enacted, perceived, internalized), psychological processes, and depression.

OBJECTIVE

We aimed to test the psychological mediation framework among transgender and cisgender sexual minorities in Kingston, Montego Bay, and Ocho Rios, Jamaica.

METHODS

We conducted structural equation modeling using maximum likelihood estimation to examine direct and indirect pathways from sexual stigma to recent (past 2-week) depressive symptoms via mediators of resilient coping, social support quantity, and empowerment, and the moderation effect of social support quality.

RESULTS

Model 1 used a latent sexual stigma construct (indicators: enacted, perceived, and internalized stigma dimensions). Model 2 examined sexual stigma dimensions (enacted, perceived, internalized) as observed variables. Among participants (n=871; mean age: 25.5, SD: 5.4), 90.82% reported recent depressive symptoms. Both models fit the data well. In Model 1, the sexual stigma latent construct had a significant direct effect on depressive symptoms; social support quantity and resilient coping were partial mediators. In Model 2, enacted sexual stigma had a significant direct effect on depressive symptoms. Internalized sexual stigma had a significant indirect effect via social support quantity, resilient coping, and empowerment. Perceived sexual stigma had an indirect effect on depressive symptoms via empowerment. Social support quality moderated the relationship between: internalized stigma and empowerment, empowerment and resilient coping, social support quantity and resilient coping, and resilient coping and depressive symptoms.

CONCLUSION

Findings suggest the importance of considering the synergistic effect of multiple sexual stigma dimensions on depression; exploring different sexual stigma dimensions to inform tailored stigma reduction and stigma coping interventions; andaddressing coping (e.g., resilience), social isolation (e.g., social support quantity/quality), and cognitive (e.g., empowerment) factors to mitigate the impacts of sexual stigma on depression among sexual minorities.

Instruments for Measuring the Resilience of Indigenous Adolescents: An Exploratory Review

Introduction: Resilience is enabled by internal, individual assets as well as the resources available in a person's environment to support healthy development. For Indigenous people, these resources and assets can include those which enhance cultural resilience. Measurement instruments which capture these core resilience constructs are needed, yet there is a lack of evidence about which instruments are most appropriate and valid for use with Indigenous adolescents. The current study reviews instruments which have been used to measure the resilience of Indigenous adolescents in Canada, Australia, New Zealand, and the United States (the CANZUS nations). The aim is to provide guidance for the future use of instruments to measure resilience among Indigenous adolescents and provide recommendations for research to strengthen evidence in this area. Method: Instruments were identified through a systematic search of resilience intervention and indicator studies targeting Indigenous youth from CANZUS nations. The studies were analyzed for information on the constructs of resilience measured in the instruments, their use with the targeted groups, and their psychometric properties. A second search was conducted to fill in any gaps in information. Instruments were included if they measured at least one construct of resilience reflecting individual assets, environmental resources, and/or cultural resilience. Results: A total of 20 instruments were identified that measured constructs of resilience and had been administered to Indigenous adolescents in the CANZUS nations. Instruments which measured both individual assets and environmental resources (n = 7), or only environmental resources (n = 6) were most common. Several instruments (n = 5) also measured constructs of cultural resilience, and two instruments included items addressing all three constructs of individual assets, environmental resources, and cultural resilience. The majority of the reviewed studies tested the reliability (75%) and content or face validity (80%) of instruments with the target population. Conclusion: There are several validated instruments available to appropriately measure constructs of resilience with Indigenous adolescents from CANZUS nations. Further work is needed on developing a consistent framework of resilience constructs to guide research efforts. Future instrument development and testing ought to focus on measures which include elements of all three core constructs critical to Indigenous adolescent resilience.

Feasibility and acceptability of Indigenous Counselling and Nicotine (ICAN) QUIT in Pregnancy multicomponent implementation intervention and study design for Australian Indigenous pregnant women: A pilot cluster randomised step-wedge trial

BACKGROUND

Many health providers (HPs) lack knowledge, confidence, optimism and skills in addressing smoking with pregnant women. This study aimed to explore the feasibility and acceptability of a) a co-designed multi-component intervention for HPs at Aboriginal Medical Services (AMSs) in culturally-targeted pregnancy-specific smoking cessation care and b) the study design.

METHODS

Using a randomised step-wedge cluster design, the Indigenous Counselling And Nicotine (ICAN) QUIT in Pregnancy Trial was evaluated across six AMSs in three Australian states. HPs were provided educational resource packages including live interactive webinars, treatment manuals, patient resources, carbon monoxide (CO) meters, and oral Nicotine Replacement Therapy (NRT). Feasibility was assessed through recruitment and retention rates of both pregnant women (12-weeks) and HPs (end of study) as well as the potential to improve women's quit rates. Qualitative interviews with staff post-trial explored acceptability of the intervention and study, based on capability, opportunity and motivation from the Behaviour Change Wheel.

RESULTS

Pregnant women (n = 22; 47% (95% CI: 32%, 63%) eligible) and HPs (n = 50; 54% (95% CI: 44%, 64%) eligible) were recruited over 6 months with retention rates of 77% (95% CI: 57%, 90%) and 40% (95% CI: 28%, 54%) respectively. Self-reported 12-week 7-day point-prevalence abstinence was 13.6% (n = 3) and validated abstinent with CO readings ≤6 ppm. Staff interviewed regarding intervention implementation highlighted the importance of provision and use of resources, including training materials, patient resources, CO meters and oral NRT. Resources helped increase capability and opportunity, restructure the environment, and provided social comparison and modelling. Staff were motivated by greater engagement with pregnant women and seeing the women's reductions in CO readings. Having the intervention at the AMSs improved organisational capacity to engage with pregnant women. Staff reported changes to their routine practice that were potentially sustainable. Recommendations for improvement to the implementation of the intervention and research included reducing training length and the tasks related to conducting the study.

CONCLUSION

ICAN QUIT in Pregnancy was a pilot study with the ability to enrol Indigenous women. It was feasible to implement and acceptable to most staff of the AMSs in three states, with modifications recommended. Smoking in pregnancy is a key challenge for Indigenous health. The intervention needs to be evaluated through a methodologically rigorous fully-powered study to determine the efficacy of outcomes for women.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry, ACTRN12616001603404. Registered 21 November 2016 - retrospectively registered, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371778.

Protocol for a feasibility study of an Indigenous Medication Review Service (IMeRSe) in Australia

INTRODUCTION

The age-adjusted rate of potentially preventable hospitalisations for Aboriginal and Torres Strait Islander people is almost five times the rate of other Australians. Quality use of medicines has an important role in alleviating these differences. This requires strengthening existing medication reviewing services through collaboration between community pharmacists and health workers, and ensuring services are culturally appropriate. This Indigenous Medication Review Service (IMeRSe) study aims to develop and evaluate the feasibility of a culturally appropriate medication management service delivered by community pharmacists in collaboration with Aboriginal health workers.

METHODS AND ANALYSIS

This study will be conducted in nine Aboriginal health services (AHSs) and their associated community pharmacies in three Australian states over 12 months. Community pharmacists will be trained to improve their awareness and understanding of Indigenous health and cultural issues, to communicate the quality use of medicines effectively, and to strengthen interprofessional relationships with AHSs and their staff. Sixty consumers (with a chronic condition/pregnant/within 2 years post partum and at risk of medication-related problems (MRPs) per site will be recruited, with data collection at baseline and 6 months. The primary outcome is the difference in cumulative incidence of serious MRPs in the 6 months after IMeRSe introduction compared with the 6 months prior. Secondary outcomes include potentially preventable medication-related hospitalisations, medication adherence, total MRPs, psychological and social empowerment, beliefs about medication, treatment satisfaction and health expenditure.

ETHICS AND DISSEMINATION

The protocol received approval from Griffith University (HREC/2018/251), Queensland Health Metro South (HREC/18/QPAH/109), Aboriginal Health and Medical Research Council of New South Wales (1381/18), Far North Queensland (HREC/18/QCH/86-1256) and the Central Australian HREC (CA-18-3090). Dissemination to Indigenous people and communities will be a priority. Results will be available on the Australian Sixth Community Pharmacy Agreement website and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ACTRN12618000188235; Pre-results.

The evidence needed to demonstrate impact: A synthesis of the evidence from a phased social and emotional wellbeing intervention

Policy decisions are based on evidence that demonstrates the effectiveness of interventions; however, the quantity and type of evidence that is needed to demonstrate the effectiveness of an intervention is not universally agreed upon. The aim of this study was to collaborate with researchers who have not been involved directly in Family Wellbeing interventions to lead a review of characteristics of the Family Wellbeing intervention evaluation output to date, and to assess for evidence of the FWB intervention's impact on participants and their communities. The study found that where it is not appropriate or viable to conduct research, such as randomised control trials, alternative ways of providing evidence to demonstrate the effectiveness of an intervention is vital. This review suggests that Family Wellbeing interventions are having a positive impact and promoting change in the lives of participants, their families and their communities. Hence, for complex interventions, such as those with Indigenous populations, evidence should demonstrate effectiveness against prescribed outcomes, as well as critical aspects behind how and why a complex intervention was successful.

Development of the Measure of Experiential Aspects of Participation for People With Physical Disabilities

OBJECTIVES

To create a parsimonious, psychometrically sound measure of experiential aspects of participation (MeEAP) for people with physical disabilities.

DESIGN

Cross-sectional.

SETTING

Online survey.

PARTICIPANTS

Respondents were a purposive sample of adults (N=228, n=118 female, mean age=49.66±14.71, range=19-83). Each respondent indicated having a physical disability and participating in employment, mobility, sport, and/or exercise life domains.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

The MeEAP was designed to be conceptually aligned with 6 experiential aspects of participation among people with physical disabilities: autonomy, belongingness, challenge, engagement, mastery, and meaning.¹ The measure was also designed to be relevant across employment, mobility, sport, and exercise life domains. Higher scores on MeEAP items were hypothesized to be associated with higher levels of life satisfaction.

RESULTS

The final 12-item scale (2 items per subscale) had strong model fit (Satorra-Bentler scaled χ²₍₃₉₎=58.26, P<.001, comparative fit index=.98, Tucker-Lewis index=.96, root mean square error of approximation=.05, standardized root mean square residual=.03) and good reliability and validity estimates. Results of regression analyses indicated that the MeEAP explained 10%-29% of the variance in life satisfaction.

CONCLUSIONS

The MeEAP is the first measure to capture all 6 experiential aspects of participation for individuals with physical disabilities across 4 major life domains. The MeEAP can be used as an outcome measure or as a mediator to help explain broader outcomes (eg, life satisfaction). The MeEAP could also be used for program evaluation to provide insights about the types of interventions needed to promote full participation.

Understanding remote Aboriginal drug and alcohol residential rehabilitation clients: Who attends, who leaves and who stays?

INTRODUCTION AND AIMS

Aboriginal residential rehabilitation services provide healing for Aboriginal people who misuse substances. There is limited available research that empirically describes client characteristics of these services. This study examined 5 years of data of a remote Aboriginal residential rehabilitation service.

DESIGN AND METHODS

Retrospective analysis of 329 client admissions to Orana Haven Drug and Alcohol Rehabilitation Centre from 2011 to 2016. Multinomial and binary logistic regressions were conducted to identify trends in the data.

RESULTS

There were 66 admissions recorded annually, of which most identified as Aboriginal (85%). Mean length of stay was 56 days, with one in three (36%) discharging within the first month. A third (32%) completed, 47% self-discharged and 20% house-discharged from the program. Client age significantly increased over time (P = 0.03), with most aged from 26 to 35. Older clients were significantly more likely to readmit (P < 0.002) and stay longer than 90 days (P = 0.02). Most clients were referred from the criminal justice system, significantly increasing from 79% (2011-2012) to 96% (2015-2016) (P < 0.001) and these clients were more likely to self-discharge (P < 0.01). Among a subset of clients, most (69%) reported concerns with polysubstance use and half (51%) reported mental illness.

DISCUSSION AND CONCLUSIONS

The current study makes a unique contribution to the literature by empirically describing the characteristics of clients of a remote Aboriginal residential rehabilitation service to more accurately tailor the service to the client's needs. Key recommendations include integrating these empirical observations with staff and client perceptions to co-design a model of care, standardise data collection, and routinely following-up clients to monitor treatment effectiveness.

The development of a healing model of care for an Indigenous drug and alcohol residential rehabilitation service: a community-based participatory research approach

BACKGROUND

Given the well-established evidence of disproportionately high rates of substance-related morbidity and mortality after release from incarceration for Indigenous Australians, access to comprehensive, effective and culturally safe residential rehabilitation treatment will likely assist in reducing recidivism to both prison and substance dependence for this population. In the absence of methodologically rigorous evidence, the delivery of Indigenous drug and alcohol residential rehabilitation services vary widely, and divergent views exist regarding the appropriateness and efficacy of different potential treatment components. One way to increase the methodological quality of evaluations of Indigenous residential rehabilitation services is to develop partnerships with researchers to better align models of care with the client's, and the community's, needs. An emerging research paradigm to guide the development of high quality evidence through a number of sequential steps that equitably involves services, stakeholders and researchers is community-based participatory research (CBPR). The purpose of this study is to articulate an Indigenous drug and alcohol residential rehabilitation service model of care, developed in collaboration between clients, service providers and researchers using a CBPR approach.

METHODS/DESIGN

This research adopted a mixed methods CBPR approach to triangulate collected data to inform the development of a model of care for a remote Indigenous drug and alcohol residential rehabilitation service.

RESULTS

Four iterative CBPR steps of research activity were recorded during the 3-year research partnership. As a direct outcome of the CBPR framework, the service and researchers co-designed a Healing Model of Care that comprises six core treatment components, three core organisational components and is articulated in two program logics. The program logics were designed to specifically align each component and outcome with the mechanism of change for the client or organisation to improve data collection and program evaluation.

CONCLUSION

The description of the CBPR process and the Healing Model of Care provides one possible solution about how to provide better care for the large and growing population of Indigenous people with substance misuse issues. [corrected].

Psychological empowerment of NGO women in Iran: Designing a tool

Background

As the core of health promotion, proper assessment of empowerment is a base for planning for a process that increases people’s control on their decisions, lifestyle, and effective activities for their health.

Objective

To design and develop a special tool to assess the empowerment of NGO women in Iran.

Methods

This successive exploratory study of combinational type was conducted in 2015 in two steps. In the first step, using comments of participants and the help of authentic texts related to this field, dimensions of psychological empowerment were developed. In the second step, psychometric properties of the scale or tool were determined using formal content, and structural validity and reliability were determined using internal consistency and stability via SPSS version 21.

Results

In the first step, the initial tool including 58 items was developed in the form of eight domains. In the second step, based on exploratory factor analysis (EFA), the number of items was reduced to 37. Considering the eigenvalues of higher than one, items were classified into eight factors. KMO index was 0.896 in this study. Reliability of the tool was 0.81 using Cronbach’s alpha. This tool is able to predict 66.1% of total changes in psychological empowerment.

Conclusion

A questionnaire with relevant reliability and validity, including eight domains of participation, motivation, cognitive thinking, critical thinking, self-efficacy, intention, perceived control and social support was developed to measure psychological empowerment of NGO women in Iran.

Delivering an empowerment intervention to a remote Indigenous child safety workforce: Its economic cost from an agency perspective

BACKGROUND

The Family Wellbeing (FWB) program applies culturally appropriate community led empowerment training to enhance the personal development of Aboriginal and Torres Strait Islander people in life skills. This study sought to estimate the economic cost required to deliver the FWB program to a child safety workforce in remote Australian communities.

METHOD

This study was designed as a retrospective cost description taken from the perspective of a non-government child safety agency. The target population were child protection residential care workers aged 24 or older, who worked in safe houses in five remote Indigenous communities and a regional office during the study year (2013). Resource utilization included direct costs (personnel and administrative) and indirect or opportunity costs of participants, regarded as absence from work.

RESULTS

The total cost of delivering the FWB program for 66 participants was $182,588 ($2766 per participant), with 45% ($82,995) of costs classified as indirect (i.e., opportunity cost of participants time). Training cost could be further mitigated (∼30%) if offered on-site, in the community. The costs for offering the FWB program to a remotely located workforce were high, but not substantial when compared to the recruitment cost required to substitute a worker in remote settings.

CONCLUSION

An investment of $2766 per participant created an opportunity to improve social and emotional wellbeing of remotely located workforce. This cost study provided policy relevant information by identifying the resources required to transfer the FWB program to other remote locations. It also can be used to support future comparative cost and outcome analyses and add to the evidence base around the cost-effectiveness of empowerment programs.

The Indigenous Counselling and Nicotine (ICAN) QUIT in Pregnancy Pilot Study protocol: a feasibility step-wedge cluster randomised trial to improve health providers' management of smoking during pregnancy

INTRODUCTION

Indigenous women have the highest smoking prevalence during pregnancy (47%) in Australia. Health professionals report lack of knowledge, skills and confidence to effectively manage smoking among pregnant women in general. We developed a behaviour change intervention aimed to improve health professionals' management of smoking in Indigenous pregnant women-the Indigenous Counselling And Nicotine (ICAN) QUIT in Pregnancy. This intervention includes webinar training for health professionals, an educational resources package for health professionals and pregnant women, free oral nicotine replacement therapy (NRT) for pregnant women, and audit and feedback on health professionals' performance.The aim of this study is to test the feasibility and acceptability of the ICAN QUIT in Pregnancy intervention to improve health professionals' provision of evidence-based culturally responsive smoking cessation care to Australian Indigenous pregnant smokers.

METHODS AND ANALYSIS

This protocol describes the design of a step-wedge cluster randomised pilot study. Six Aboriginal Medical Services (AMSs) are randomised into three clusters. Clusters receive the intervention staggered by 1 month. Health professionals report on their knowledge and skills pretraining and post-training and at the end of the study. Pregnant women are recruited and followed up for 3 months. The primary outcome is the recruitment rate of pregnant women. Secondary outcomes include feasibility of recruitment and follow-up of participating women, and webinar training of health professionals, measured using a designated log; and measures of effectiveness outcomes, including quit rates and NRT prescription rates.

ETHICS AND DISSEMINATION

In accordance with the Aboriginal Health and Medical Research Council guidelines, this study has been developed in collaboration with a Stakeholder and Consumer Aboriginal Advisory Panel (SCAAP). The SCAAP provides cultural consultation, advice and direction to ensure that implementation is acceptable and respectful to the Aboriginal communities involved. Results will be disseminated to AMSs, Aboriginal communities and national Aboriginal bodies.

REGISTRATION DETAILS

This protocol (version 4, 14 October 2016) is registered with the Australian and New Zealand Clinical Trials Registry (Ref #: ACTRN12616001603404).

Social and Emotional Wellbeing Screening for Aboriginal and Torres Strait Islanders within Primary Health Care: A Series of Missed Opportunities?

BACKGROUND

Social and emotional wellbeing (SEWB) is a critical determinant of health outcomes for Indigenous Australians. This study examined the extent to which primary healthcare services (PHSs) undertake SEWB screening and management of Aboriginal and Torres Strait Islander clients, and the variation in SEWB screening and management across Indigenous PHS.

METHODS

Cross-sectional analysis between 2012 and 2014 of 3,407 Indigenous client records from a non-representative sample of 100 PHSs in 4 Australian states/territory was undertaken to examine variation in the documentation of: (1) SEWB screening using identified measurement instruments, (2) concern regarding SEWB, (3) actions in response to concern, and (4) follow up actions. Binary logistic regression was used to determine the factors associated with screening.

RESULTS

The largest variation in SEWB screening occurred at the state/territory level. The mean rate of screening across the sample was 26.6%, ranging from 13.7 to 37.1%. Variation was also related to PHS characteristics. A mean prevalence of identified SEWB concern was 13% across the sample, ranging from 9 to 45.1%. For the clients where SEWB concern was noted, 25.4% had no referral or PHS action recorded. Subsequent internal PHS follow up after 1 month occurred in 54.7% of cases; and six-monthly follow up of referrals to external services occurred in 50.9% of cases.

CONCLUSION

Our findings suggest that the lack of a clear model or set of guidelines on best practice for screening for SEWB in Indigenous health may contribute to the wide variation in SEWB service provision. The results tell a story of missed opportunities: 73.4% of clients were not screened and no further action was taken for 25.4% for whom an SEWB concern was identified. There was no follow up for just under half of those for whom action was taken. There is a need for the development of national best practice guidelines for SEWB screening and management, accompanied by dedicated SEWB funding, and training for health service providers as well as ongoing monitoring of adherence with the guidelines. Further research on barriers to screening and follow up actions is also warranted.

Social and emotional wellbeing assessment instruments for use with Indigenous Australians: A critical review

RATIONALE

There is growing recognition that in addition to universally recognised domains and indicators of wellbeing (such as population health and life expectancy), additional frameworks are required to fully explain and measure Indigenous wellbeing. In particular, Indigenous Australian wellbeing is largely determined by colonisation, historical trauma, grief, loss, and ongoing social marginalisation. Dominant mainstream indicators of wellbeing based on the biomedical model may therefore be inadequate and not entirely relevant in the Indigenous context. It is possible that "standard" wellbeing instruments fail to adequately assess indicators of health and wellbeing within societies that have a more holistic view of health.

OBJECTIVE

The aim of this critical review was to identify, document, and evaluate the use of social and emotional wellbeing measures within the Australian Indigenous community.

METHOD

The instruments were systematically described regarding their intrinsic properties (e.g., generic v. disease-specific, domains assessed, extent of cross-cultural adaptation and psychometric characteristics) and their purpose of utilisation in studies (e.g., study setting, intervention, clinical purpose or survey). We included 33 studies, in which 22 distinct instruments were used.

RESULTS

Three major categories of social and emotional wellbeing instruments were identified: unmodified standard instruments (10), cross-culturally adapted standard instruments (6), and Indigenous developed measures (6). Recommendations are made for researchers and practitioners who assess social and emotional wellbeing in Indigenous Australians, which may also be applicable to other minority groups where a more holistic framework of wellbeing is applied.

CONCLUSION

It is advised that standard instruments only be used if they have been subject to a formal cross-cultural adaptation process, and Indigenous developed measures continue to be developed, refined, and validated within a diverse range of research and clinical settings.