Chronic diseases, including cardiovascular disease (CVD) and diabetes, are the most significant contributors to health disparities experienced by Aboriginal and Torres Strait Islander people.1 The majority of the mortality gap (approximately 80%) is accounted for by chronic diseases.1 Rates of CVD and diabetes are disproportionately higher in the Aboriginal and Torres Strait Islander population.2 Collectively, these two conditions account for approximately 35% of the life expectancy gap between Aboriginal and Torres Strait Islander peoples and non-Indigenous people in Australia.3
The National Aboriginal and Torres Strait Islander Health Plan 2013–2023 acknowledges the significant role of health promotion in supporting health gain; “Australia's health system supports universal and affordable access to high-quality medical, pharmaceutical and hospital services, whereas helping people to stay healthy through health promotion and disease prevention activities.”4(p.2) Health promotion is a broad field of work as indicated in the following definition:
“Health promotion enables people to increase control over, and to improve their health and its determinants. Health promotion activities are designed to improve or protect health within social, physical, economic and political contexts. Health promotion includes public policy interventions (e.g. packaging of cigarettes, seat belt laws), information to support healthy lifestyles (e.g. smoking, alcohol and drug use, physical activity, diet), social marketing (e.g. sunscreen, safe sex) and mass media campaigns (e.g. drink driving, road safety). Health promotion also, includes promoting social responsibility for health, empowering individuals, strengthening community capacity and addressing determinants of health.”5(p.125)
Health promotion encompasses many types of interventions, including screening and prevention, and targets more than the behaviors of individuals, which are important in improving the health and wellbeing of populations. The social determinants of health, such as housing, employment and education, are also critical targets for health promotion policy and practice. As such, the health sector alone will be unable to close the health and wellbeing gap between Indigenous and non-Indigenous Australians.6 This review will focus on health promotion activities that are likely to have learnings relevant to the Aboriginal and Torres Strait Islander primary health care (PHC) sector.
According to the Aboriginal and Torres Strait Islander health organisations online report, from 2012 to 2013, 71% of Aboriginal and Torres Strait Islander PHC services offered healthy lifestyle programs.7 There is, however, a lack of evidence informing PHC health promotion programs.8 Even though the body of evidence is continuing to grow, there are some areas for which there is still insufficient studies, especially for the context or population group for which the program is to be implemented.8 Health promotion programs implemented in PHC settings are rarely evaluated rigorously or have findings disseminated widely to add to the evidence base. There are several reasons for this, including a lack of resourcing allocated to sufficiently collect data, evaluate program outcomes and disseminate the findings.9 Staff implementing health promotion activities in the PHC setting are not always qualified in health promotion and may lack the skills to effectively evaluate health promotion programs and publish the findings. In addition, the short-term funding cycles for health promotion activities often result in a lack of continuity in the programs and therefore a lack of any long-term results or evaluations.9
Scoping reviews are used to map the literature, collating the evidence on a specific topic and summarizing the characteristics and findings of the studies.10 This review will follow the methodology for scoping reviews outlined by Peters et al.10 This scoping review will highlight the existing evidence and provide insight into topic areas which could benefit from further synthesis or development of the evidence base. This scoping review will clearly outline the available evidence and provide guidance for subsequent priority reviews to build the evidence base which could inform health promotion practice and policy in the Aboriginal and Torres Strait Islander PHC settings.
The National Health and Medical Research Council funded Centre for Research Excellence in Aboriginal Chronic Disease Knowledge Translation and Exchange has consulted widely with the Aboriginal health sector.11 These representatives and organizations have been integral in identifying research priorities to inform practice and policy in the Aboriginal and Torres Strait Islander health sector to ultimately improve the health and wellbeing of Aboriginal and Torres Strait Islanders. Through this consultation, health promotion was identified as a key topic for evidence synthesis.11
A preliminary search of the literature was conducted and confirmed that a scoping review has not been previously published on this topic. The preliminary search found a number of primary studies and systematic reviews which contribute but do not individually provide sufficient evidence to identify and describing existing research on health promotion programs and activities. We anticipate, however, that these publications will likely be included in this scoping review.
Studies will be included if the participants were Aboriginal and Torres Strait Islander peoples living in Australia. Studies that include participants of other ethnicities will be considered if either the majority of participants were Aboriginal or Torres Strait Islander (more than 50%) or if they provide results for the Aboriginal and Torres Strait Islander participants separately. There is no exclusion criteria based on participant age or morbidity status.
To be included, health promotion activities and programs must be delivered to individuals and/or groups by appropriately trained staff that aim to prevent or manage chronic disease by modifying the following lifestyle behaviors; tobacco smoking, nutrition, alcohol, physical activity and social and emotional wellbeing.
These specific risk factors have been chosen as they were identified by the Australian Institute of Health and Welfare1 as major contributors to the current gap in health between Indigenous and non-Indigenous Australians. In addition, smoking, alcohol use, poor nutrition and a lack of exercise are the major risk factors associated with chronic disease in Australian population more generally. There are no exclusion criteria based on the length or frequency of the program or activity.
The chronic diseases that the health promotion activity aims to prevent or manage are those that are the biggest contributors to the life expectancy and morbidity gap: metabolic syndrome, diabetes mellitus, CVD, obesity, chronic kidney disease and/or depression as determined by the study.
Health promotion activities focused on disease caused primarily by parasites or pathogens will not be included despite the evidence linking some such conditions with chronic diseases listed above, for example, dental plaque with heart disease or scabies with chronic kidney disease. Programs for the management of asthma and mental illnesses other than depression will also be excluded from this review.
Health promotion limited to only policies, such as healthy catering, no smoking policies, environmental policies or urban design modification or the provision of information in the form of posters, brochures, online websites or smartphone applications without any personal contact with appropriately trained staff supporting these health promotion activities/advice will not be included. Health promotion activities that focus on a pharmaceutical only interventions will also be excluded.
Health promotion activities and programs delivered in all regions (urban, rural and remote) and any setting (PHC centres, schools, workplaces or community centres) will be included if participants continue to live in their usual environment. Programs implemented in a live-in facility, such as alcohol or drug rehabilitation or a facility for diagnosed mental illness, will not be included.
Types of sources
All qualitative, quantitative, economic and mixed methods studies will be considered for inclusion. In addition, reviews including programs that meet the inclusion criteria will also be retrieved. Policy studies and expert opinion will not be included.
The search strategy aims to find both commercially published and grey literature. Consultation with a health research librarian identified five key electronic databases: PubMed, CINAHL, Informit (Health Collection and Indigenous Peoples Collection), Scopus and Trove. The search in Trove will be limited to theses only as other publication types should be captured in the remaining databases. An initial limited search of PubMed will be undertaken followed by analysis of the text words contained in the title and abstract and the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. The search will not be limited by date and will go back as far as the databases allow.
To capture additional literature, a search of websites and clearing houses that provide information, links and resources related to Aboriginal and Torres Strait Islander health will also be completed. The search strategy across websites will be modified as required. The sites to be searched are:
- Australian Institute of Aboriginal and Torres Strait Islander Studies
- The Lowitja Institute
- Australian Government Office of Aboriginal and Torres Strait Islander Health
- National Aboriginal Community Controlled Health Organisation
- Australian Health and Medical Research Council of New South Wales
- Victorian Aboriginal Community Controlled Health Organisation
- Queensland Aboriginal and Islander Health Council
- Aboriginal Health Council of South Australia
- Aboriginal Health Council of Western Australia
- Aboriginal Medical Services Alliance Northern Territory
- Central Australian Aboriginal Congress
- Aboriginal and Torres Strait Islander PHC services identified by the authors and leadership group
Initial search terms will include: Indigenous, Aboriginal or Torres Strait Islander, health promotion, smoking, nicotine, nutrition, physical activity, exercise, alcohol, grog, social and emotional, depression, mental health, self-care, self-management, resilience, quality of life, diabetes management, diabetes prevention, obesity, cardiovascular disease, metabolic syndrome, kidney disease, depression, chronic disease management or chronic disease prevention.
Articles will be assessed for inclusion based on the previously mentioned inclusion criteria examining them by title and abstract. Full text of the articles will be retrieved if they appear to meet the inclusion criteria or if further examination is required to determine the eligibility of the study. Two reviewers will independently confirm if the full text article meets the inclusion criteria. Any disagreements will be resolved by a third reviewer.
The relevant content from each study will be extracted with the assistance of data extraction tools. Data extracted will include; author(s), year of publication, aims/objectives, program setting, participants inclusion criteria (age, sex, ethnicity), condition of focus (if applicable), risk factors addressed and the key outcomes. Data extraction for the primary studies will also include a brief description of the program (Appendix I). If more than one paper is found for a study or project, they will be treated as one for data extraction. If a review describes multiple health promotion programs but does no synthesis of data, individual programs that meet the inclusion criteria will be extracted separately.
Presentation of findings
The results of the search strategy will be presented in a PRISMA flow diagram indicating the number of articles found via each search method and the articles excluded. A list of articles excluded at full text will be available including the main reason the article was excluded.
Study characteristics from the data extraction will be presented in the form of a table with accompanying narrative. The characteristics reported will include citation, research aim or questions, the population or participants, study design, chronic disease of focus, and a description of the program/activity.
If possible, depending on the nature of the studies found, the results will also be depicted in an evidence map, similar to those used to illustrate 3ie gap maps.12 The evidence map, like a gap map, will represent programs in the rows and key outcomes in the columns.13 The representation of results will be dependent on the studies included.
This scoping review is supported by a Centre of Research Excellence in Aboriginal Chronic Disease Knowledge Translation and Exchange (CREATE) funded by the National Health and Medical Research Council (#1061242). The scope of this review was developed in consultation with the CREATE leadership group comprising representatives from the Aboriginal and Torres Strait Islander Health Sector.