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Background: In recent decades, financial investment has been made in health-related programs and services to overcome inequities and improve Indigenous people's wellbeing in Australia and New Zealand. Despite policies aiming to 'close the gap', limited evaluation evidence has informed evidence-based policy and practice. Indigenous leaders have called for evaluation stakeholders to align their practices with Indigenous approaches., Methods: This study aimed to strengthen culturally safe evaluation practice in Indigenous settings by engaging evaluation stakeholders, in both countries, in a participatory concept mapping study. Concept maps for each country were generated from multi-dimensional scaling and hierarchical cluster analysis., Results: The 12-cluster Australia map identifies four cluster regions: An Evaluation Approach that Honours Community; Respect and Reciprocity; Core Heart of the Evaluation; and Cultural Integrity of the Evaluation. The 11-cluster New Zealand map identifies four cluster regions: Authentic Evaluation Practice; Building Māori Evaluation Expertise; Integrity in Māori Evaluation; and Putting Community First. Both maps highlight the importance of cultural integrity in evaluation. Differences include the distinctiveness of the 'Respecting Language Protocols' concept in the Australia map in contrast to language being embedded within the cluster of 'Knowing Yourself as an Evaluator in a Māori Evaluation Context' in the New Zealand map. Participant ratings highlight the importance of all clusters with some relatively more difficult to achieve, in practice. Notably, the 'Funding Responsive to Community Needs and Priorities' and 'Translating Evaluation Findings to Benefit Community' clusters were rated the least achievable, in Australia. The 'Conduct of the Evaluation' and the 'Prioritising Māori Interests' clusters were rated as least achievable in New Zealand. In both countries, clusters of strategies related to commissioning were deemed least achievable., Conclusions: The results suggest that the commissioning of evaluation is crucial as it sets the stage for whether evaluations: reflect Indigenous interests, are planned in ways that align with Indigenous ways of working and are translated to benefit Indigenous communities Identified strategies align with health promotion principles and relational accountability values of Indigenous approaches to research. These findings may be relevant to the commissioning and conduct of Indigenous health program evaluations in developed nations.

Background: Aboriginal Community Controlled Organisations (ACCOs) provide community-focussed and culturally safe services for First Peoples in Australia, including crisis intervention and health promotion activities, in a holistic manner. The ecological model of health promotion goes some way towards describing the complexity of such health programs. The aims of this project were to: 1) identify the aims and purpose of existing health promotion programs conducted by an alliance of ACCOs in northern Victoria, Australia; and 2) evaluate the extent to which these programs are consistent with an ecological model of health promotion, addressing both individual and environmental determinants of health., Methods: The project arose from a long history of collaborative research. Three ACCOs and a university formed the Health Promotion Alliance to evaluate their health promotion programs. Local community members were trained in, and contributed to developing culturally sensitive methods for, data collection. Information on the aims and design of 88 health promotion activities making up 12 different programs across the ACCOs was systematically and prospectively collected., Results: There was a wide range of activities addressing environmental and social determinants of health, as well as physical activity, nutrition and weight loss. The design of the great majority of activities had a minimal Western influence and were designed within a local Aboriginal cultural framework. The most common focus of the activities was social connectedness (76 %). Physical activity was represented in two thirds of the activities, and nutrition, weight loss and culture were each a focus of about half of the activities. A modified coding procedure designed to assess the ecological nature of these programs showed that they recruited from multiple settings; targeted a range of individual, social and environmental determinants; and used numerous and innovative strategies to achieve change., Conclusion: First Peoples' health promotion in the Goulburn-Murray Rivers region encompasses a broad range of social, cultural, lifestyle and community development activities, including reclaiming and strengthening cultural identity and social connectedness as a response to colonisation.

Issue addressed The context of community-based childhood obesity prevention programs can influence the effects of these intervention programs. Leadership readiness for community mobilisation for childhood obesity prevention is one such contextual factor. This study assessed perceived community leadership readiness (PCLR) at two time points in a state-wide, multisite community-based childhood obesity prevention program. Methods PCLR was assessed across 168 suburbs of 20 intervention communities participating in South Australia's Obesity Prevention and Lifestyle (OPAL) program. Using a validated online PCLR tool, four key respondents from each community rated each suburb within their respective community on a nine-point scale for baseline and 2015. Average PCLR and change scores were calculated using the general linear model with suburbs nested in communities. Relationships between demographic variables and change in PCLR were evaluated using multiple regression. Ease of survey use was also assessed. Results Average PCLR increased between baseline (3.51, s.d.=0.82) and 2015 (5.23, s.d.=0.89). PCLR rose in 18 of 20 intervention communities. PCLR was inversely associated with suburb population size (r 2 =0.03, P=0.03, β=-0.25) and positively associated with intervention duration (r 2 change=0.08, P=0.00, β=0.29). Only 8% of survey respondents considered the online assessment tool difficult to use. Conclusions PCLR increased over the course of the OPAL intervention. PCLR varied between and within communities. Online assessment of PCLR has utility for multisite program evaluations. So what? Use of a novel, resource-efficient online tool to measure the key contextual factors of PCLR has enabled a better understanding of the success and generalisability of the OPAL program.

Background: An ecological approach to health and health promotion targets individuals and the environmental determinants of their health as a means of more effectively influencing health outcomes. The approach has potential value as a means to more accurately capture the holistic nature of Australian First Peoples' health programs and the way in which they seek to influence environmental, including social, determinants of health., Methods: We report several case studies of applying an ecological approach to health program evaluation using a tool developed for application to mainstream public health programs in North America - Richard's ecological coding procedure., Results: We find the ecological approach in general, and the Richard procedure specifically, to have potential for broader use as an approach to reporting and evaluation of health promotion programs. However, our experience applying this tool in academic and community-based program evaluation contexts, conducted in collaboration with First Peoples of Australia, suggests that it would benefit from cultural adaptations that would bring the ecological coding procedure in greater alignment with the worldviews of First Peoples and better identify the aims and strategies of local health promotion programs., Conclusions: Establishing the cultural validity of the ecological coding procedure is necessary to adequately capture the underlying program activities of community-based health promotion programs designed to benefit First Peoples, and its collaborative implementation with First Peoples supports a human rights approach to health program evaluation.

Background: Community readiness for facilitation and uptake of interventions can impact the success of community-based prevention efforts. As currently practiced, measuring community readiness can be a resource intensive process, compromising its use in evaluating multisite community-based prevention efforts. The purpose of this study was to develop, test and validate a more efficient online version of an existing community readiness tool and identify potential problems in completing assessments. This study was conducted in the context of a complex community-based childhood obesity prevention program in South Australia., Methods: Following pre-testing, an online version of the community readiness tool was created, wherein respondents, with detailed knowledge of their community and prevention efforts, rated their communities on five anchored rating scales (Knowledge of Efforts, Leadership, Knowledge of the Issue, Community Climate, and Resources). Respondents completed the standard, over-the-phone community readiness interview ("gold standard") and the new online survey. Paired t-test, St. Laurent's correlation coefficient and intra-class correlation (ICC) were used to determine the validity of the online tool. Contact summary forms were completed after each interview to capture interview quality., Results: Twenty-five respondents completed both assessments. There was a statistically significant difference in the overall community readiness scores between the two methods (paired t-test p = 0.03); online scores were consistently higher than interview scores. St. Laurent's correlation of 0.58 (95% CI 0.42-0.73) was moderate; the ICC of 0.65 (95% CI 0.35-0.83) was good. Only for the leadership and resources dimensions was there no statistically significant difference between the scores from the two methods (p = 0.61, p = 0.08 respectively). St Laurent's correlation (r = 0.83, 95% CI 0.71-0.92) and the ICC (0.78, 95% CI 0.57-0.90) were excellent for leadership. Qualitative results from the standard interview method suggest that some respondents felt reluctant to answer questions on behalf of other community members. This may have impacted their self-selected ratings and/or responses to questions during the interview., Conclusions: Concurrent validity for the online method was supported for the Leadership dimension only. However, the online method holds promise as it reduces time and resource burden, allowing for a quicker return of results to the community to inform program planning, implementation and evaluations to improve community health.

Background: A systematic review characterised and synthesised applications of the Community Readiness Tool (CRT) and synthesised quantitative results for readiness applications at multiple time points., Methods: Eleven databases in OvidSP and EBSCHOhost were searched to retrieve CRT applications. Information from primary studies was extracted independently by two researchers., Results: Forty applications of the CRT met inclusion criteria focussing on 14 different health and social issues. The community of interest was most often defined solely on the basis of its geographical location (52.5%). Most studies used the CRT to plan (85%) and/or evaluate programs (40%). The CRT protocol was modified in 40% of studies. Six applications evaluated readiness at multiple time points, however limited reporting in primary studies precluded any synthesis of results. Applications identified methodological rigour, contextual information and community engagement as strengths, and time and resource costs as limitations., Conclusions: The CRT is well suited for planning and evaluating complex community health interventions given its flexibility to accommodate diverse definitions of community and issues. CRT applications would benefit from improved reporting; reporting recommendations for use of the CRT are outlined.

Little research has assessed the fidelity, adaptation or integrity of activities implemented within community-based obesity prevention initiatives. To address this gap, a mixed-method process evaluation was undertaken in the context of the South Australian Obesity Prevention and Lifestyle (OPAL) initiative. An ecological coding procedure assessed fidelity and adaptation of activity settings, targets and strategies implemented in the second year of four communities. Implementation integrity reflected fidelity and adaptation to local context, whereas efforts resulting in significant deviations from the original plan were deemed to lack fidelity and integrity. Staff implemented 284 strategies in 205 projects. Results show that 68.3 and 2.1% of strategies were implemented with fidelity or adapted, respectively. Overall, 70.4% of all strategies were implemented with integrity. Staff experienced barriers with 29.6% of strategies. Chi-square analyses show statistically significant associations between implementation integrity and strategy type, intervention and behavioural targets. These relationships are weak to modest. The strongest relationship was found between implementation integrity and proximal target. Staff experienced implementation barriers at the coalition, policy, organization, interpersonal and community levels. The greatest range of barriers was encountered working with organizations. To overcome these barriers, staff took greater ownership, invested more time, persisted and allocated more financial resources., (© The Author 2014. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Ecological intervention programs are recommended to prevent overweight and obesity in children. The National Institute of Public Health (INSP) in Mexico implemented a successful ecological intervention program to promote healthy lifestyle behaviors in school age children. This study assessed the integration of ecological principles and Social Cognitive Theory (SCT) constructs in this effective school-based obesity prevention program implemented in 15 elementary schools in Mexico City., Methods: Two coders applied the Intervention Analysis Procedure (IAP) to "map" the program's integration of ecological principles. A checklist gauged the use of SCT theory in program activities., Results: Thirty-two distinct intervention strategies were implemented in one setting (i.e., school) to engage four different target-groups (students, parents, school representatives, government) across two domains (Nutrition and Physical Activity). Overall, 47.5% of the strategies targeted the school infrastructure and/or personnel; 37.5% of strategies targeted a key political actor, the Public Education Secretariat while fewer strategies targeted parents (12.5%) and children (3%). More strategies were implemented in the Nutrition domain (69%) than Physical Activity (31%). The most frequently used SCT construct within both intervention domains was Reciprocal Determinism (e.g., where changes to the environment influence changes in behavior and these behavioral changes influence further changes to the environment); no significant differences were observed in the use of SCT constructs across domains., Conclusions: Findings provide insight into a promising combination of strategies and theoretical constructs that can be used to implement a school-based obesity prevention program. Strategies emphasized school-level infrastructure/personnel change and strong political engagement and were most commonly underpinned by Reciprocal Determinism for both Nutrition and Physical Activity.

Objective: Effective interventions to improve population and individual health require environmental change as well as strategies that target individual behaviours and clinical factors. This is the basis of implementing an ecological approach to health programs and health promotion. For Aboriginal People and Torres Strait Islanders, colonisation has made the physical and social environment particularly detrimental for health., Methods and Results: We conducted a literature review to identify Aboriginal health interventions that targeted environmental determinants of health, identifying 21 different health programs. Program activities that targeted environmental determinants of health included: Caring for Country; changes to food supply and/or policy; infrastructure for physical activity; housing construction and maintenance; anti-smoking policies; increased workforce capacity; continuous quality improvement of clinical systems; petrol substitution; and income management. Targets were categorised according to Miller's Living Systems Theory. Researchers using an Indigenous community based perspective more often identified interpersonal and community-level targets than were identified using a Western academic perspective., Conclusions: Although there are relatively few papers describing interventions that target environmental determinants of health, many of these addressed such determinants at multiple levels, consistent to some degree with an ecological approach. Interpretation of program targets sometimes differed between academic and community-based perspectives, and was limited by the type of data reported in the journal articles, highlighting the need for local Indigenous knowledge for accurate program evaluation., Implications: While an ecological approach to Indigenous health is increasingly evident in the health research literature, the design and evaluation of such programs requires a wide breadth of expertise, including local Indigenous knowledge.

In regional Australia "communities of place," defined as bounded geographic locations with a local society, undertake community-wide primary prevention programs. In helping to prevent chronic illness, communities provide valuable resources to the health system. To understand the role of community-health sector partnerships for primary prevention and the community contextual factors that affect them, we studied eight partnerships. We used an embedded multiple case study design and collected data through interviews, nonparticipant observation, and document analysis. These data were analyzed using a typology of community-health sector partnerships and community interaction theory to frame the key community contextual factors that affected partnerships. The dominant factor affecting all partnerships was the presence of a collective commitment that communities brought to making the community a better place through developing health. We call this a communitarian approach. Additional research to investigate factors influencing a communitarian approach and the role it plays in partnerships is required.

Aboriginal Australians, including Aboriginal Health Workers (AHWs), smoke at rates double the non-Aboriginal population. This study utilized concept mapping methodology to identify and prioritize culturally relevant strategies to promote smoking cessation in AHWs. Stakeholder participants included AHWs, other health service employees and tobacco control personnel. Smoking cessation strategies (n = 74) were brainstormed using 34 interviews, 3 focus groups and a stakeholder workshop. Stakeholders sorted strategies into meaningful groups and rated them on perceived importance and feasibility. A concept map was developed using multi-dimensional scaling and hierarchical cluster analyses. Ten unique clusters of smoking cessation strategies were depicted that targeted individuals, family and peers, community, workplace and public policy. Smoking cessation resources and services were represented in addition to broader strategies addressing social and environmental stressors that perpetuate smoking and make quitting difficult. The perceived importance and feasibility of clusters were rated differently by participants working in health services that were government-coordinated compared with community-controlled. For health service workers within vulnerable populations, these findings clearly implicate a need for contextualized strategies that mitigate social and environmental stressors in addition to conventional strategies for tobacco control. The concept map is being applied in knowledge translation to guide development of smoking cessation programs for AHWs.

PURPOSE. To assess the evolution of perceived ownership of a university-Aboriginal community partnership across three project stages. DESIGN. Survey administration to project partners during project formalization (1996-T1), mobilization (1999-T2), and maintenance (2004-T3). SETTING. Aboriginal community of Kahnawake, outside Montreal, Quebec, Canada. PARTICIPANTS. Partners involved in influencing decision making in the Kahnawake Schools Diabetes Prevention Project (KSDPP). MEASURE AND ANALYSIS . A measure of perceived primary ownership subjected to linear trend analysis. RESULTS. KSDPP staff were perceived as primary owner at T1 and shared ownership with Community Advisory Board (CAB) members at T2 and T3. Trend tests indicated greater perceived ownership between T1 and T3 for CAB (χ(2)(1)  =  12.3, p < .0001) and declining KSDPP staff (χ(2)(1)  =  10.5, p < .001) ownership over time. Academic partners were never perceived as primary owners. CONCLUSION. This project was community driven from the beginning. It was not dependent on an external academic change agent to activate the community and develop the community's capacity to plan and implement a solution. It still took several years for the grassroots CAB to take responsibility from KSDPP staff, thus indicating the need for sustained funding to build grassroots community capacity.

Background: For health promotion to be effective in Aboriginal and Torres Strait Islander Communities, interventions (and their evaluation) need to work within a complex social environment and respect Indigenous knowledge, culture and social systems. At present, there is a lack of culturally appropriate evaluation methods available to practitioners that are capable of capturing this complexity. As an initial response to this problem, we used two non-invasive methods to evaluate a community-directed health promotion program, which aimed to improve nutrition and physical activity for members of the Aboriginal community of the Goulburn-Murray region of northern Victoria, Australia. The study addressed two main questions. First, for members of an Aboriginal sporting club, what changes were made to the nutrition environment in which they meet and how is this related to national guidelines for minimising the risk of chronic disease? Second, to what degree was the overall health promotion program aligned with an ecological model of health promotion that addresses physical, social and policy environments as well as individual knowledge and behaviour?, Methods: Rather than monitoring individual outcomes, evaluation methods reported on here assessed change in the nutrition environment (sports club food supply) as a facilitator of dietary change and the 'ecological' nature of the overall program (that is, its complexity with respect to numbers of targets, settings and strategies)., Results: There were favourable changes towards the provision of a food supply consistent with Australian guidelines at the sports club. The ecological analysis indicated that the design and implementation of the program were consistent with an ecological model of health promotion., Conclusions: The evaluation was useful for assessing the impact of the program on the nutrition environment and for understanding the ecological nature of program activities.

Background: Public health promotes an ecological approach to chronic disease prevention, however, little research has been conducted to assess the integration of an ecological approach in community-based prevention programs. This study sought to contribute to the evidence base by assessing the extent to which an ecological approach was integrated into an Aboriginal community-based cardiovascular disease (CVD) and type 2 diabetes prevention program, across three-intervention years., Methods: Activity implementation forms were completed by interview with implementers and participant observation across three intervention years. A standardised ecological coding procedure was applied to assess participant recruitment settings, intervention targets, intervention strategy types, extent of ecologicalness and organisational partnering. Inter-rater reliability for two coders was assessed at Kappa = 0.76 (p < .0.001), 95% CI (0.58, 0.94)., Results: 215 activities were implemented across three intervention years by the health program (HP) with some activities implemented in multiple years. Participants were recruited most frequently through organisational settings in years 1 and 2, and organisational and community settings in year 3. The most commonly utilised intervention targets were the individual (IND) as a direct target, and interpersonal (INT) and organisational (ORG) environments as indirect targets; policy (POL), and community (COM) were targeted least. Direct (HP→ IND) and indirect intervention strategies (i.e., HP→ INT→ IND, HP→ POL → IND) were used most often; networking strategies, which link at least two targets (i.e., HP→[ORG-ORG]→IND), were used the least. The program did not become more ecological over time., Conclusions: The quantity of activities with IND, INT and ORG targets and the proportion of participants recruited through informal cultural networking demonstrate community commitment to prevention. Integration of an ecological approach would have been facilitated by greater inter-organisational collaboration and centralised planning. The upfront time required for community stakeholders to develop their capacity to mobilise around chronic disease is at odds with short-term funding cycles that emphasise organisational accountability.

Health promotion emphasizes the importance of community ownership in the governance of community-based programmes, yet little research has been conducted in this area. This study examined perceptions of community ownership among project partners taking responsibility for decision-making related to the Kahnawake Schools Diabetes Prevention Project (KSDPP). Project partners were surveyed cross-sectionally at 18 months (T1) and 60 months (T2) into the project. The perceived influence of each project partner was assessed at T1 and T2 for three domains: (i) KSDPP activities; (ii) KSDPP operations; and (iii) Community Advisory Board (CAB) activities. Project staff were perceived to have the greatest influence on KSDPP activities, KSDPP operations and CAB activities at both T1 and T2. High mean scores of perceived influence for CAB members and community researchers, however, suggests that project decision-making was a shared responsibility among multiple community partners. Although academic researcher influence was consistently low, they were satisfied with their level of influence. This was unlike community affiliates, who were less satisfied with their lower level of influence. In keeping with Kanien'kehaka (Mohawk) culture, the findings suggest a participatory democracy or shared decision-making as the primary mode of governance of KSDPP.

Community public health interventions based on citizen and community participation are increasingly discussed as promising avenues for the reduction of health inequalities and the promotion of social justice. However, very few authors have provided explicit principles and guidelines for planning and implementing such interventions, especially when they are linked with research. Traditional approaches to public health programming emphasise expert knowledge, advanced detailed planning, and the separation of research from intervention. Despite the usefulness of these approaches for evaluating targeted narrow-focused interventions, they may not be appropriate in community health promotion, especially in Aboriginal communities. Using the experience of the Kahnawake Schools Diabetes Prevention Project, in Canada, this paper elaborates four principles as basic components for an implementation model of community programmes. The principles are: (1) the integration of community people and researchers as equal partners in every phase of the project, (2) the structural and functional integration of the intervention and evaluation research components, (3) having a flexible agenda responsive to demands from the broader environment, and (4) the creation of a project that represents learning opportunities for all those involved. The emerging implementation model for community interventions, as exemplified by this project, is one that conceives a programme as a dynamic social space, the contours and vision of which are defined through an ongoing negotiation process.

Little research has assessed the fidelity, adaptation or integrity of activities implemented within community-based obesity prevention initiatives. To address this gap, a mixed-method process evaluation was undertaken in the context of the South Australian Obesity Prevention and Lifestyle (OPAL) initiative. An ecological coding procedure assessed fidelity and adaptation of activity settings, targets and strategies implemented in the second year of four communities. Implementation integrity reflected fidelity and adaptation to local context, whereas efforts resulting in significant deviations from the original plan were deemed to lack fidelity and integrity. Staff implemented 284 strategies in 205 projects. Results show that 68.3 and 2.1% of strategies were implemented with fidelity or adapted, respectively. Overall, 70.4% of all strategies were implemented with integrity. Staff experienced barriers with 29.6% of strategies. Chi-square analyses show statistically significant associations between implementation integrity and strategy type, intervention and behavioural targets. These relationships are weak to modest. The strongest relationship was found between implementation integrity and proximal target. Staff experienced implementation barriers at the coalition, policy, organization, interpersonal and community levels. The greatest range of barriers was encountered working with organizations. To overcome these barriers, staff took greater ownership, invested more time, persisted and allocated more financial resources.

Aboriginal Australians, including Aboriginal Health Workers (AHWs), smoke at rates double the non-Aboriginal population. This study utilized concept mapping methodology to identify and prioritize culturally relevant strategies to promote smoking cessation in AHWs. Stakeholder participants included AHWs, other health service employees and tobacco control personnel. Smoking cessation strategies (n = 74) were brainstormed using 34 interviews, 3 focus groups and a stakeholder workshop. Stakeholders sorted strategies into meaningful groups and rated them on perceived importance and feasibility. A concept map was developed using multi-dimensional scaling and hierarchical cluster analyses. Ten unique clusters of smoking cessation strategies were depicted that targeted individuals, family and peers, community, workplace and public policy. Smoking cessation resources and services were represented in addition to broader strategies addressing social and environmental stressors that perpetuate smoking and make quitting difficult. The perceived importance and feasibility of clusters were rated differently by participants working in health services that were government-coordinated compared with community-controlled. For health service workers within vulnerable populations, these findings clearly implicate a need for contextualized strategies that mitigate social and environmental stressors in addition to conventional strategies for tobacco control. The concept map is being applied in knowledge translation to guide development of smoking cessation programs for AHWs.

This study reports on the development and evaluation of a rating tool to assess the scientific utility and cultural appropriateness of community-level indicators for application with Indigenous populations. Indicator criteria proposed by the U.S. Institute of Medicine were culturally adapted through reviewing the literature and consultations with academic and Indigenous stakeholders. Pre-testing and collaborator feedback drove the iterative development of the tool with stakeholder groups in Canada, Aotearoa/New Zealand, and Australia. Pilot testing with 17 raters across countries involved rating the same selection of six health and social indicators using a six-point ordinal scale. The final version of the rating tool includes 16 questions within three criterion domains: "importance," "soundness," and "viability." Academic and community stakeholder review established face and content validity. The indicator rating tool demonstrated good internal consistency and excellent inter-rater reliability for two of three pilot testing groups. Use of this instrument can strengthen collaborative research planning and evaluation with Indigenous communities through selection of relevant and culturally appropriate indicators for application to public health research, prevention programmes, and health and social policy.

Democratic or equal participation in decision making is an ideal that community and academic stakeholders engaged in participatory research strive to achieve. This ideal, however, may compete with indigenous peoples' right to self-determination. Study objectives were to assess the perceived influence of multiple community (indigenous) and academic stakeholders engaged in the Kahnawake Schools Diabetes Prevention Project (KSDPP) across six domains of project decision making and to test the hypothesis that KSDPP would be directed by community stakeholders. Self-report surveys were completed by 51 stakeholders comprising the KSDPP Community Advisory Board (CAB), KSDPP staff, academic researchers and supervisory board members. KSDPP staff were perceived to share similar levels of influence with (i) CAB on maintaining partnership ethics and CAB activities and (ii) academic researchers on research and dissemination activities. KSDPP staff were perceived to carry significantly more influence than other stakeholders on decisions related to annual activities, program operations and intervention activities. CAB and staff were the perceived owners of KSDPP. The strong community leadership aligns KSDPP with a model of community-directed research and suggests that equitable participation--distinct from democratic or equal participation--is reflected by indigenous community partners exerting greater influence than academic partners in decision making. (Contains 4 tables and 1 figure.)

Health and social indicators that capture the distinct historical, social, and cultural contexts of Indigenous communities can play an important role in informing the planning and delivery of community interventions. There is currently considerable interest in cataloguing and vetting meaningful community-level health and social indicators that could be applied to research and health promotion activities in Indigenous communities in Australia, Canada, and New Zealand, inclusive of conventional indicators as well as measures developed specifically for use in or with Indigenous communities. To avoid haphazard selection of indicators, and to assure the comprehensiveness and relevance of any given set of indicators, a framework that can accommodate and conceptually classify indicators representing a full range of domains is required. We report here on the development of a conceptual framework, by which Indigenous community indicators, and more general community-level social indicators, can be sorted, catalogued, and systematically classified within four hierarchical levels. The indicator framework was developed across Canada, Australia and New Zealand in consultation with academic researchers and Indigenous community stakeholders, building from established health and social indicator systems. The Indigenous indicator framework permits Indigenous communities, public health researchers, and funding agencies to compare and select the most appropriate indicators for application in specific contexts from the multitude of existing indicators.

Purpose: Although implementation fidelity is an important component in the evaluation of school health promotion programs, it assumes that teaching is the most relevant teacher role. To understand the social context of program implementation, a qualitative study was undertaken with the aim of identifying the schoolteacher's role in implementing the objectives of the Kahnawake Schools Diabetes Prevention Project (KSDPP), a locally governed Kanienke:haka (Mohawk) community-based diabetes prevention program. Design/methodology/approach: Prospective semi-structured interviews were conducted cross-sectionally with 30 teachers, two administrators and one physical education teacher across four intervention years. Interviews were analysed retrospectively using qualitative thematic analysis. Findings: In implementing KSDPP objectives teachers adopted, to varying degrees, the roles of teaching the health education curriculum, enforcing the school nutrition policy, role modelling healthy lifestyles, and encouraging healthy lifestyles. Taken together, these roles point to a high-order role of teachers taking responsibility for enabling healthy lifestyles in their children, which is congruent with a wholistic approach to health. Study findings suggest that children in different classrooms were exposed to a different intervention dose based on the extent to which teachers applied each role. Research limitations/implications: The findings suggest that the current conceptualisation of implementation fidelity should be expanded to account for the influence of the social context (i.e. teachers' roles) on the implementation of health promotion program objectives. Originality/value: Consistent with an ecological approach to intervention, teachers would benefit from interventions that predispose, enable, and reinforce their capacity to adopt and apply health promotion roles. (Contains 1 figure and 1 table.)

Issue addressed: To describe the need for high school sleep education from the perspective of undergraduate university students. Methods: Undergraduate students who completed an online course on sleep and circadian health were surveyed 6 months after course completion. Students were asked whether a similar course would have benefited them as high school students, and about the need for sleep education in high schools. Thematic analysis of this qualitative data was carried out. Results: Eighty‐nine students who had attended 71 unique high schools provided responses. Eight‐one per cent thought they would have benefitted from a similar course during high school and identified domains of sleep knowledge particularly relevant to high school students. They cited environmental barriers to healthy sleep present during high school and believed that sleep education could improve students' lifestyle, sleep and performance. Nineteen per cent of students said they would not have benefited, because they perceived sleeping patterns during high school to be nonmodifiable or believed that previous sleep education was sufficient. Of the respondents who did not think students would benefit, 53% would still tell their high school principal that there was a need for sleep education. Conclusions: The findings support the need for engaging sleep education for high school students. Future studies should examine the perspectives of students in high school directly, rather than undergraduate students who have already shown an interest in sleep health. So what?: Sleep health is missing from the Australian school curriculum. Online courses may be an engaging method of promoting sleep and circadian health to high school students. [ABSTRACT FROM AUTHOR]

Issue addressed: Internationally, universities have recognised the benefits of Pet Support Programs (PSPs). However, existing literature has predominately focused on quantitatively measuring health outcomes associated with a PSP amongst student populations. This research aimed to explore the feasibility of a PSP within an Australian university, as there is a need to explore practical considerations involved in implementation. Methods: This research used a qualitative descriptive approach. Participants were recruited via purposive snowball sampling. The sample included 17 participants across eight administrative divisions within an Australian university. Semi‐structured individual interviews were used to collect data. Data were analysed using thematic analysis. Results: Three main themes emerged from the data: Organisational Change, Program Management and Perceived Outcomes. Findings suggest several considerations from both an organisational and program level that need to be addressed prior to implementation, including the university's policies, the location and animal welfare. The main perceived outcomes were stress relief and social support. Ways to minimise risks to those who may have an aversion towards animals were also discussed. Conclusions: Participants believed implementing a PSP would be feasible in the university setting, provided all aforementioned considerations were adequately addressed. Considerations identified have the potential to act as a barrier or a facilitator depending on how they are managed. So what?: Where feasible and later implemented, a PSP could provide Australian university students and staff with an alternative means of improving mental health, providing stress relief and contributing towards the Health Promoting University framework. [ABSTRACT FROM AUTHOR]

Issues addressed: The significant investment in health research has resulted in an increased focus to determine suitable approaches to measure health promotion research impact. This research was undertaken at the request of a nationally competitive research organisation that funds health promotion research, to explore how Chief Investigators (CIs) on their funded projects understood research impact, its measurement and associated challenges. Methods: Participants were required to be or have been a CI on an Australian competitive research (exploratory or intervention) grant focussed on health promotion. The qualitative study used thematic analysis from one‐on‐one interviews. Themes were created and descriptive quotes were selected to illustrate the main findings. Results: The majority of participants were female (n = 13) working at a university (n = 13). Three themes emerged: a) defining health research impact; b) complexity and simplicity of measuring health research impact; c) challenges of measuring health research impact: i) differing language; ii) differing assessment; iii) attribution and timing; and iv) resourcing and skills. Conclusion: Researchers recognised that there are significant challenges in measuring the impact of health promotion research. The most significant factors identified by participants were the disciplinary background of the researchers undertaking the measurement, their skills and experience and the resources (including time) available to assess impact. So what?: Research impact assessment is complex, time consuming and requires specific skills to facilitate measurement of impact provision of funding for this activity in research grants and research impact training is required. [ABSTRACT FROM AUTHOR]

This study sought to assess factors associated with quality of life (QoL), and predictive of improvements in QoL over time, in a population-based cohort study. A 4-year longitudinal survey was administered to 2433 individuals at the study baseline; of these, 1828 individuals participated in Wave 2, and 1303 participated in Wave 3. QoL was measured by the Satisfaction with Life Domains Scale. Thirty-two variables were correlated with baseline QoL and together explained 58.2% of the variance. Eleven variables were independent predictors of improvement in QoL over time. Among these variables, social support and stress/coping showed the strongest association with QoL, and neighbourhood characteristics had an additional influence. Multidimensional modelling of a broad spectrum of the factors related to QoL enabled situating mental health and well-being in an ecological system with attendant implications for public health and social policy intervention to facilitate improvement of QoL in the population. [ABSTRACT FROM AUTHOR]

A Theory of Change (ToC) is an approach to map programmes aimed at inducing change in a specific context, with the goal of increasing their impact. We applied this approach to the specific case of handwashing and sanitation practices in low- and middle-income countries and developed a ToC as part of a systematic review exercise. Different existing sources of information were used to inform the initial draft of the ToC. In addition, stakeholder involvement occurred and peer review took place. Our stakeholders included methodological (ToC/quantitative and qualitative research) and content experts (WASH (Water, Sanitation, Hygiene)/behaviour change), as well as end-users/practitioners, policy-makers and donors. In conclusion, the development of a ToC, and the involvement of stakeholders in its development, was critical in terms of understanding the context in which the promotional programmes are being implemented. We recommend ToC developers to work with stakeholders to create a ToC relevant for practice. [ABSTRACT FROM PUBLISHER]

Background: Aboriginal and Torres Strait Islander women experience higher rates of obesity, chronic disease, and are less active than non-Indigenous Australian women. Lifestyle programs designed to increase physical activity and encourage healthy eating are needed to ameliorate this disparity. The aim of this study was to identify participants' perceived barriers and enablers to attend group exercise classes as part of a 12-week fitness program. Methods: To understand the factors that influence attendance, a mixed method process evaluation was undertaken in which a quantitative measure of attendance in the group exercise classes was used to identify cases for further qualitative investigation. Aboriginal and/or Torres Strait Islander women aged 18 to 64 years were recruited to a research trial of a fitness program. The 12-week program included two 60-minute group exercise classes per week, and four nutrition education workshops. Semi-structured interviews were conducted at program completion. Participants were stratified by attendance, and interviews from the highest and lowest 25 percentiles analysed. Rigour was strengthened through use of multiple data analysts, member checking and prolonged engagement in the field. Results: Analyses of the post-program interviews revealed that participants enrolled in the program primarily for the perceived health benefits and all (with one exception) found the program met their needs and expectations. The atmosphere of classes was positive and comfortable and they reported developing good relationships with their fellow participants and program staff. Low attendees described more barriers to attendance, such as illness and competing work and family obligations, and were more likely to report logistical issues, such as inconvenient venue or class times. Conclusions: Attendance to the 'Aboriginal and Torres Strait Islander Women's Fitness Program' was primarily influenced by the participant's personal health, logistics and competing obligations. Low attendees reported more barriers during the 12-week period and identified fewer enabling factors than high attendees. Trial registration: Australian New Zealand Clinical Trials Registry ACTRN12610000224022 [ABSTRACT FROM AUTHOR]

The Australian health system requires novel strategies to implement widespread primary prevention to reduce the burden of chronic illness. One approach is for health sectors to draw on resources available in communities of place and to form partnerships which maximize the relevance and uptake of initiatives designed to promote healthy lifestyles. This article presents a typology of conceptual approaches to community and health sector partnerships, developed through an extensive literature search and empirically tested using in-depth case studies across regional Australia. The article finds that the health sector’s orientation to primary prevention is generally instrumental involving highly targeted outcomes and pre-defined programmes. Communities of place have multifaceted priorities that include building the social and economic sustainability of their community. While these approaches might appear incompatible, careful ‘manipulation’ and ‘massaging’ of instrumental objectives to adjust to community agendas and the presence of ‘boundary crossers’ can lead to successful primary prevention outcomes. [ABSTRACT FROM AUTHOR]

Background: Aboriginal and Torres Strait Islander women experience higher rates of heart disease and type 2 diabetes than non-Indigenous Australian women. Increasing physical activity, improving diets and losing weight have been shown to reduce cardio metabolic risk. The primary aim was to evaluate the effectiveness of a 12-week structured exercise and nutrition program in a cohort of urban Indigenous Australian women on waist circumference, weight and biomedical markers of metabolic functioning from baseline (T1) to program completion (T2). The secondary aim assessed whether these outcomes were maintained at 3-month follow-up Methods: One hundred Aboriginal and/or Torres Strait Islander women aged 18-64 years living in the Adelaide metropolitan area were recruited. The program included two 60-minute group cardiovascular and resistance training classes per week, and four nutrition education workshops. Participants were randomly assigned to an 'active' group or 'waitlisted' control group. Body weight, height, waist and hip circumference, blood pressure, fasting glucose, fasting insulin, glycated haemoglobin (HbA1C), lipid profile and C-reactive protein (CRP) were assessed at baseline (T1), immediately after the program (T2) and three months post program (T3). Results: The active group showed modest reductions in weight and body mass index (BMI). Compared to the waitlisted group, the active group had a statistically significantly change in weight and BMI from baseline assessments; at T2, -1.65 kg and -0.66 kg/m² and at T3, -2.50 kg and -1.03 kg/m², respectively. Systolic and diastolic blood pressure also had a statistically significant difference from baseline in the active group compared to the waitlisted group at T2, -1.24 mmHg and -2.46 mmHg and at T3, -4.09 mmHg and -2.17 mmHg, respectively. The findings were independent of the baseline measure of the outcome variable, age, households with children and employment status. Changes in waist circumference and other clinical measures were not significant at T2 or T3. The primary outcome measure, waist circumference, proved problematic to assess reliably. Missing data and participants lost to follow-up were significant. Conclusions: This 12-week exercise program demonstrated modest reductions in weight, BMI and blood pressure at T2, which improved further at 3-month follow-up (T3). Positive intervention effects were observed despite low attendance at exercise classes. Structured exercise programs implemented in community settings require attention to understanding the barriers to participation for this high risk group. [ABSTRACT FROM AUTHOR]

The Kahnawake Schools Diabetes Prevention Project (KSDPP) is an ongoing participatory research and intervention project aimed at the primary prevention of type 2 diabetes. Formally initiated in 1994 with strong community support, KSDPP provides a fertile opportunity to learn about how a community came to identify the need for preventive action on a health problem such as diabetes. The purpose of our study was to describe the various conditions in the community of Kahnawake, which gave rise to its mobilization for the prevention of type 2 diabetes. Qualitative data consisted of 12 individual interviews and one focus group with key community members and health professionals living and/or working in the community of Kahnawake, along with historically relevant documents. The data collection and analysis procedures of the grounded theory method were applied. Results describe a preceding phase to formal KSDPP implementation, triggered by returning research results on the community prevalence of type 2 diabetes. This phase of ‘legitimizing diabetes as a community health issue’ is characterized by a shift in the perceived preventability of diabetes among community members; from a problem that was to be lived with to a problem that was to be prevented. The shift in perceptions was facilitated by the context in the community, described by structural developments, cognitive and relational elements. In addition to reaffirming the critical importance of utilizing lay knowledge during the planning of a health promotion intervention, our study has uncovered some of the key conditions through which individuals in the community came to participate in the identification and planning of a diabetes prevention project. [ABSTRACT FROM AUTHOR]