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High prevalence of chronic and infectious diseases in Indigenous populations is a major public health concern both in global and Australian contexts. Limited research has examined the role of built environments in relation to Indigenous health in remote Australia. This study engaged stakeholders to understand their perceptions of the influence of built environmental factors on chronic and infectious diseases in remote Northern Territory (NT) communities. A preliminary set of 1120 built environmental indicators were systematically identified and classified using an Indigenous Indicator Classification System. The public and environmental health workforce was engaged to consolidate the classified indicators (n = 84), and then sort and rate the consolidated indicators based on their experience with living and working in remote NT communities. Sorting of the indicators resulted in a concept map with nine built environmental domains. Essential services and Facilities for health/safety were the highest ranked domains for both chronic and infectious diseases. Within these domains, adequate housing infrastructure, water supply, drainage system, reliable sewerage and power infrastructure, and access to health services were identified as the most important contributors to the development of these diseases. The findings highlight the features of community environments amenable to public health and social policy actions that could be targeted to help reduce prevalence of chronic and infectious diseases Refereed/Peer-reviewed

The high prevalence of preventable infectious and chronic diseases in Australian Indigenous populations is a major public health concern. Existing research has rarely examined the role of built and socio-political environmental factors relating to remote Indigenous health and wellbeing. This research identified built and socio-political environmental indicators from publicly available grey literature documents locally-relevant to remote Indigenous communities in the Northern Territory (NT), Australia. Existing planning documents with evidence of community input were used to reduce the response burden on Indigenous communities. A scoping review of community-focused planning documents resulted in the identification of 1120 built and 2215 socio-political environmental indicators. Indicators were systematically classified using an Indigenous indicator classification system (IICS). Applying the IICS yielded indicators prominently featuring the “community infrastructure” domain within the built environment, and the “community capacity” domain within the socio-political environment. This research demonstrates the utility of utilizing existing planning documents and a culturally appropriate systematic classification system to consolidate environmental determinants that influence health and disease occurrence. The findings also support understanding of which features of community-level built and socio-political environments amenable to public health and social policy actions might be targeted to help reduce the prevalence of infectious and chronic diseases in Indigenous communities Refereed/Peer-reviewed

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. Refereed/Peer-reviewed

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. Refereed/Peer-reviewed

A scoping review of grey and peer-reviewed literature was conducted to develop a conceptual framework to illustrate mechanisms involved in reducing HIV stigma and increasing HIV test uptake. We followed a 3-step approach to exploring the literature: developing concepts, organizing and categorizing concepts, and synthesizing concepts into a framework. The framework contains 4 types of intervention strategies: awareness creation, influencing normative behavior, providing support, and developing regulatory laws. The awareness creation strategy generally improves knowledge and the influencing normative behavior strategy changes stigmatizing attitudes and behaviors, and subsequently, increases HIV test uptake. Providing support and development of regulatory law strategies changes actual stigmatizing behaviors of the people and, subsequently, increases HIV test uptake. The framework further outlines that the mechanisms described are influenced by the interaction of various social-contextual and individual factors. The framework sheds new light on the effects of HIV stigma reduction intervention strategies and HIV test uptake. publisher: Elsevier articletitle: Building a Conceptual Framework to Study the Effect of HIV Stigma-Reduction Intervention Strategies on HIV Test Uptake: A Scoping Review journaltitle: Journal of the Association of Nurses in AIDS Care articlelink: http://dx.doi.org/10.1016/j.jana.2017.04.004 content_type: article copyright: © 2017 Association of Nurses in AIDS Care ispartof: Journal of the Association of Nurses in Aids Care vol:28 issue:4 pages:545-560 ispartof: location:United States status: published

Background/Aim: This study tested the utility of retrospectively staging cancer registry data for comparing stage and stage-specific survivals of Aboriginal and non-Aboriginal people. Differences by area level factors were also explored. Methods: This test dataset comprised 950 Aboriginal cases and all other cases recorded on the South Australian cancer registry with a 1977–2010 diagnosis. A sub-set of 777 Aboriginal cases diagnosed in 1990–2010 were matched with randomly selected non-Aboriginal cases by year of birth, diagnostic year, sex, and primary site of cancer. Competing risk regression summarised associations of Aboriginal status, stage, and geographic attributes with risk of cancer death. Results: Aboriginal cases were 10 years younger at diagnosis, more likely to present in recent diagnostic years, to be resident of remote areas, and have primary cancer sites of head & neck, lung, liver and cervix. Risk of cancer death was associated in the matched analysis with more advanced stage at diagnosis. More Aboriginal than non-Aboriginal cases had distant metastases at diagnosis (31.3% vs 22.0, p < 0.001). After adjusting for stage, remote-living Aboriginal residents had higher risks of cancer death than Aboriginal residents of metropolitan areas. Non-Aboriginal cases had the lowest risk of cancer death. Conclusion: Retrospective staging proved to be feasible using registry data. Results indicated more advanced stages for Aboriginal than matched non-Aboriginal cases. Aboriginal people had higher risks of cancer death, which persisted after adjusting for stage, and applied irrespective of remoteness of residence, with highest risk of death occurring among Aboriginal people from remote areas. Refereed/Peer-reviewed

In Australia, Aboriginal and Torres Strait Islander People carry a greater burden of cancerrelated mortality than non-Aboriginal Australians. The Cancer Data and Aboriginal Disparities Project aims to develop and test an integrated, comprehensive cancer monitoring and surveillance system capable of incorporating epidemiological and narrative data to address disparities and advocate for clinical system change. Methods and analysis: The Advanced Cancer Data System will integrate routinely collected unit record data from the South Australian Population Cancer Registry and a range of other data sources for a retrospective cohort of indigenous people with cancers diagnosed from 1990 to 2010. A randomly drawn non-Aboriginal cohort will be matched by primary cancer site, sex, age and year at diagnosis. Cross-Tabulations and regression analyses will examine the extent to which demographic attributes, cancer stage and survival vary between the cohorts. Narratives from Aboriginal people with cancer, their families, carers and service providers will be collected and analysed using patient pathway mapping and thematic analysis. Statements from the narratives will structure both a concept mapping process of rating, sorting and prioritising issues, focusing on issues of importance and feasibility, and the development of a real-Time Aboriginal Cancer Measure of Experience for ongoing linkage with epidemiological data in the Advanced Cancer Data System. Aboriginal Community engagement underpins this Project. Ethics and dissemination: The research has been approved by relevant local and national ethics committees. Findings will be disseminated in local andinternational peer-reviewed journals and conference presentations. In addition, the research will provide data for knowledge translation activities across thepartner organisations and feed directly into the Statewide Cancer Control Plan. It will provide a mechanism for monitoring and evaluating theimplementation of the recommendations in these documents. Refereed/Peer-reviewed

An underrepresentation of stakeholder perspectives within urban health research arguably limits our understanding of what is a multi-dimensional and complex relationship between the built environment and health. By engaging a wide range of stakeholders using a participatory concept mapping approach, this study aimed to achieve a more holistic and nuanced understanding of the built environments shaping disease risk, specifically cardiometabolic risk (CMR). Moreover, this study aimed to ascertain the importance and changeability of identified environments through government action. Through the concept mapping process, community members, researchers, government and non-government stakeholders collectively identified eleven clusters encompassing 102 built environmental domains related to CMR, a number of which are underrepresented within the literature. Among the identified built environments, open space, public transportation and pedestrian environments were highlighted as key targets for policy intervention. Whilst there was substantive convergence in stakeholder groups’ perspectives concerning the built environment and CMR, there were disparities in the level of importance government stakeholders and community members respectively assigned to pedestrian environments and street connectivity. These findings support the role of participatory methods in strengthening how urban health issues are understood and in affording novel insights into points of action for public health and policy intervention. Refereed/Peer-reviewed

Introduction: The increasing global prevalence of suicide has made it a major public health concern. Research designed to retrospectively study suicide cases is now being conducted in populations around the world. This field of research is especially crucial in Aboriginal populations, as they often have higher suicide rates than the rest of the country. Objective: This paper presents the methodological aspects of the first psychological autopsy study on suicide among Inuit in Nunavut. Qaujivallianiq Inuusirijauvalauqtunik (‘Learning from lives that have been lived’) is a large case-control study including all 120 cases of suicide that occurred in Nunavut between January 1 st , 2003 and December 31 st , 2006. The paper describes the research design, ethical considerations and strategies used to adapt the psychological autopsy method to Nunavut Inuit. Specifically, we present local social and cultural issues, data collection procedures, and the acceptability, reliability and validity of the method. Method: A retrospective case-control study using the psychological autopsy approach was carried out in 21 communities in Nunavut. A total of 498 individuals were directly interviewed, and medical and correctional charts were also reviewed. Results: The psychological autopsy method was well received by participants as they appreciated the opportunity to discuss the loss of a family member or friend by suicide. During interviews, informants readily identified symptoms of psychiatric disorders, although culture-specific rather than clinical explanations were sometimes provided. Results suggest that the psychological autopsy method can be effectively used in Inuit populations. Keywords: suicide; Inuit; psychological autopsy; mental health; cross-cultural; Canada; Aboriginal; Nunavut; risk factors (Published: 26 March 2013) Citation: Int J Circumpolar Health 2013, 72 : 20078 - http://dx.doi.org/10.3402/ijch.v72i0.20078

The evaluation of complex systems-wide public health interventions requires evaluation research that is underpinned by theory. This article presents and discusses the trans-disciplinary evaluation research framework developed to support the evaluation of a South Australian program called OPAL (Obesity Prevention and Lifestyle). The aim is to provide insights into the research design, methods and implementation of the evaluation and contribute to the debate on how to evaluate community-based interventions with complicated and complex aspects. In an attempt to capture the complexity of childhood obesity and the intervention, the OPAL evaluation research employs post positivist, interpretive and critical epistemologies, valuing epistemological pluralism. Each component of the multi-phase mixed methods evaluation captures different yet complementary information concerning the context, process, cost effectiveness and outcomes providing a more complete understanding of the impacts of the complex program. Evaluation research is not without challenges. Some of the tensions and challenges that arose in the establishment, planning and conduct of the OPAL program and evaluation are discussed. Refereed/Peer-reviewed

Background Several stigma reduction intervention strategies have been developed and tested for effectiveness in terms of increasing human immunodeficiency virus (HIV) test uptake. These strategies have been more effective in some contexts and less effective in others. Individual factors, such as lack of knowledge and fear of disclosure, and social-contextual factors, such as poverty and illiteracy, might influence the effect of stigma reduction intervention strategies on HIV test uptake in low- and middle-income countries. So far, it is not clearly known how the stigma reduction intervention strategies interact with these contextual factors to increase HIV test uptake. Therefore, we will conduct a review that will synthesize existing studies on stigma reduction intervention strategies to increase HIV test uptake to better understand the mechanisms underlying this process in low- and middle-income countries. Methods A realist review will be conducted to unpack context-mechanism-outcome configurations of the effect of stigma reduction intervention strategies on HIV test uptake. Based on a scoping review, we developed a preliminary theoretical framework outlining a potential mechanism of how the intervention strategies influence HIV test uptake. Our realist synthesis will be used to refine the preliminary theoretical framework to better reflect mechanisms that are supported by existing evidence. Journal articles and grey literature will be searched following a purposeful sampling strategy. Data will be extracted and tested against the preliminary theoretical framework. Data synthesis and analysis will be performed in five steps: organizing extracted data into evidence tables, theming, formulating chains of inference from the identified themes, linking the chains of inference and developing generative mechanisms, and refining the framework. Discussion This will be the first realist review that offers both a quantitative and a qualitative exploration of the available evidence to develop and propose a theoretical framework that explains why and how HIV stigma reduction intervention strategies influence HIV test uptake in low- and middle-income countries. Our theoretical framework is meant to provide guidance to program managers on identifying the most effective stigma reduction intervention strategies to increase HIV test uptake. We also include advice on how to effectively implement these strategies to reduce the rate of HIV transmission. Systematic review registration PROSPERO CRD42015023687 Electronic supplementary material The online version of this article (doi:10.1186/s13643-015-0130-3) contains supplementary material, which is available to authorized users.

Background Community-Based Participatory Research (CBPR) is an approach in which researchers and community stakeholders form equitable partnerships to tackle issues related to community health improvement and knowledge production. Our 2012 realist review of CBPR outcomes reported long-term effects that were touched upon but not fully explained in the retained literature. To further explore such effects, interviews were conducted with academic and community partners of partnerships retained in the review. Realist methodology was used to increase the understanding of what supports partnership synergy in successful long-term CBPR partnerships, and to further document how equitable partnerships can result in numerous benefits including the sustainability of relationships, research and solutions. Methods Building on our previous realist review of CBPR, we contacted the authors of longitudinal studies of academic-community partnerships retained in the review. Twenty-four participants (community members and researchers) from 11 partnerships were interviewed. Realist logic of analysis was used, involving middle-range theory, context-mechanism-outcome configuration (CMOcs) and the concept of the ‘ripple effect’. Results The analysis supports the central importance of developing and strengthening partnership synergy through trust. The ripple effect concept in conjunction with CMOcs showed that a sense of trust amongst CBPR members was a prominent mechanism leading to partnership sustainability. This in turn resulted in population-level outcomes including: (a) sustaining collaborative efforts toward health improvement; (b) generating spin-off projects; and (c) achieving systemic transformations. Conclusion These results add to other studies on improving the science of CBPR in partnerships with a high level of power-sharing and co-governance. Our results suggest sustaining CBPR and achieving unanticipated benefits likely depend on trust-related mechanisms and a continuing commitment to power-sharing. These findings have implications for building successful CBPR partnerships to address challenging public health problems and the complex assessment of outcomes. Electronic supplementary material The online version of this article (doi:10.1186/s12889-015-1949-1) contains supplementary material, which is available to authorized users.

Background Several papers report deficiencies in the reporting of information about the implementation of interventions in clinical trials. Information about implementation is also required in systematic reviews of complex interventions to facilitate the translation and uptake of evidence of provider-based prevention and treatment programs. To capture whether and how implementation is assessed within systematic effectiveness reviews, we developed a checklist for implementation (Ch-IMP) and piloted it in a cohort of reviews on provider-based prevention and treatment interventions for children and young people. This paper reports on the inter-rater reliability, feasibility and reasons for discrepant ratings. Methods Checklist domains were informed by a framework for program theory; items within domains were generated from a literature review. The checklist was pilot-tested on a cohort of 27 effectiveness reviews targeting children and youth. Two raters independently extracted information on 47 items. Inter-rater reliability was evaluated using percentage agreement and unweighted kappa coefficients. Reasons for discrepant ratings were content analysed. Results Kappa coefficients ranged from 0.37 to 1.00 and were not influenced by one-sided bias. Most kappa values were classified as excellent (n = 20) or good (n = 17) with a few items categorised as fair (n = 7) or poor (n = 1). Prevalence-adjusted kappa coefficients indicate good or excellent agreement for all but one item. Four areas contributed to scoring discrepancies: 1) clarity or sufficiency of information provided in the review; 2) information missed in the review; 3) issues encountered with the tool; and 4) issues encountered at the review level. Use of the tool demands time investment and it requires adjustment to improve its feasibility for wider use. Conclusions The case of provider-based prevention and treatment interventions showed relevancy in developing and piloting the Ch-IMP as a useful tool for assessing the extent to which systematic reviews assess the quality of implementation. The checklist could be used by authors and editors to improve the quality of systematic reviews, and shows promise as a pedagogical tool to facilitate the extraction and reporting of implementation characteristics. Electronic supplementary material The online version of this article (doi:10.1186/s12874-015-0037-7) contains supplementary material, which is available to authorized users.

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. Refereed/Peer-reviewed

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. Refereed/Peer-reviewed

Objective: The Inuit population in Canada's North has suffered from high rates of death by suicide. We report on the first large-scale, controlled, epidemiologically representative study of deaths by suicide in an Indigenous population, which investigates risk factors for suicide among all Inuit across Nunavut who died by suicide during a 4-year period. Methods: We identified all suicides by Inuit ( n = 120) that occurred between January 1, 2003, and December 31, 2006, in Nunavut. For each subject, we selected a community-matched control subject. We used proxy-based procedures and conducted structured interviews with informants to obtain life histories, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Axis I and II diagnoses, and measures of impulsive and (or) aggressive traits. Results: Compared with control subjects, subjects who died by suicide were more likely to have experienced childhood abuse (OR 2.38; 95% CI 1.39 to 4.08), have family histories of major depressive disorder ( P = 0.002) and suicide completion ( P = 0.02), and have been affected by major depressive disorder (OR 13.00; 95% CI 6.20 to 27.25), alcohol dependence (OR 2.90; 95% CI 1.59 to 5.24), or cannabis dependence (OR 3.96; 95% CI 2.29 to 6.8) in the last 6 months. In addition, subjects who died by suicide were more likely to have been affected with cluster B personality disorders (OR 10.18; 95% CI 3.34 to 30.80) and had higher scores of impulsive and aggressive traits ( P < 0.001). Conclusions: At the individual level, clinical risk factors for suicide among Inuit are similar to those observed in studies with the general population, and indicate a need for improved access to mental health services. The high rate of mental health problems among control subjects suggests the need for population-level mental health promotion.

Aims Aboriginal peoples have a high prevalence of smoking and are at major risk for diabetes. The role of insulin resistance vs. compromised β-cell function in the link between smoking and glycaemic disease is not clear. This study tested whether relations between insulin resistance and β-cell function differ between current smokers, former smokers and non-smokers, and if having diabetes modifies smoking-related effects. Methods A community-based diabetes screening initiative was mounted for a North-western First Nation (Interior Salishan) in rural British Columbia, Canada. Respondents were on-reserve Aboriginal people (n = 156), all adults 18 + years. Glycaemic status was determined by oral glucose tolerance test. Fasting values for glucose and insulin were used to estimate β-cell function and insulin resistance by homeostasis model assessment (HOMA). Analyses adjusted for age, sex, alcohol intake, education, body mass index and physical activity. Results For normoglycaemic persons (n = 119) current smokers relative to non-smokers had high β-cell values [difference (95% confidence interval) 19.5 (17.1, 21.9)], while former smokers had low β-cell values [difference −22.8 (−20.3, −25.3)] (P

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.

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.

Introduction The inequity of randomising participants to control groups in randomised controlled trials (RCTs) is often considered inappropriate, especially for research trials that include vulnerable populations such as Indigenous peoples. The Aboriginal and Torres Strait Islander Women’s Fitness Program conducted a trial that randomly assigned participants to ‘active’ and ‘waitlisted’ groups. This paper reports on participant views of the randomisation protocol. Methods A pragmatic RCT was conducted in an urban setting to assess the effectiveness of the 12-week Aboriginal and Torres Strait Islander Women’s Fitness Program on metabolic health outcomes and waist circumference. Qualitative interviews were conducted at follow-up, one of the objectives was to explore participant perspectives on the research protocol, including participant randomisation to ‘Active’ and ‘Waitlisted’ groups. Results A total of 49 interviews were conducted (26 Active and 23 Waitlisted participants). Two key factors influenced participant views on the protocol: 1) group assignment; and 2) how well they understood the research design, including the justification for randomisation. ‘Active’ participants were concerned about the inequity of the randomisation process but overall supported the study protocol. Although most Waitlisted participants were disappointed about having to wait 12-months for the program, some participants derived motivation from being waitlisted, whilst others lost motivation. Well-informed participants were more likely to express both support for the randomisation process and an understanding of the research benefits than participants not attending an information session prior to registration. Conclusions Participants were more accepting of the research protocol if it was clearly explained to them, if they understood the randomisation process and felt the randomisation was justified in terms of the potential for the results to benefit other Aboriginal and Torres Strait Islander women. Our study suggests that the time and resources required to adequately explain the research protocol in research trials should not be undervalued. Trial registration Australian New Zealand Clinical Trials Registry (ACTRN12610000224022).

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. Refereed/Peer-reviewed

The study objectives were to characterise the smoking status and quit smoking behaviour of Aboriginal Health Workers (AHWs) in South Australia (SA), Australia; and identify the psychosocial, socio-demographic, and household smoking characteristics that distinguish smokers from quitters and never smokers. A self-reported cross-sectional survey was completed by AHWs in SA. Non-parametric statistics were used for inferential analyses. Eighty-five AHWs completed surveys representing a response rate of 63.0%. The prevalence of current smokers was 50.6%. Non-smokers (49.5%) included quitters (22.4%) and never smokers (27.1%). Smoking status did not differ by gender or geographic location. Of current smokers, 69.0% demonstrated a readiness to quit and 50.0% had made at least one quit attempt in the last 12 months. Compared to quitters and never smokers, current smokers expressed lower emotional wellbeing, and three times as many resided with another smoker. Quitters had the highest levels of perceived social support and part-time employment. A high proportion of AHWs who smoke desire, and are ready to quit. Individual, social and household factors differentiated smokers from non-smokers and quitters. Social support, and relationships and structures that favour social support, are implicated as necessary to enable AHWs who smoke to act on their desire to quit smoking. Refereed/Peer-reviewed

Objective: To examine the associations between consumption of sweetened products, daytime sleepiness (DS) and psychological distress (PD) in a Catholic Middle-Eastern Canadian community, and to test the hypothesis that the association between DS and consumption of sweetened products is mediated by PD. Conclusions: The association between DS and consumption of sweetened products in the Catholic Middle-Eastern Canadian community is partially mediated by psychological distress. Further work should test this mediation relationship in larger samples and verify the potential effects of other sleep variables in this relationship. Design: A cross-sectional study. Participants: 186 men and women aged between 18 and 60 years. Primary and secondary outcome measures: Sweetened product consumption was measured using a food frequency questionnaire (total sugars/day). DS and PD were measured using standardised questionnaires. The generalised linear model was used to estimate associations between sweetened product consumption, age, sex, self-reported body mass index, DS and PD. Baron and Kenny's four-step approach in addition to the Sobel test were used to establish mediation. Results: Average DS score was 8.2 (SD=4.5) with 19.5% having excessive scores (>12). Mean PD score was 20.8 (SD=6.2) with 11.8% having high distress scores. Average consumption of sweetened products was 15.5 g/day (SD=13.9). Baron and Kenny's three steps to establish partial mediation were confirmed. First, DS was associated with consumption of sweetened products (p

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. Refereed/Peer-reviewed

Trial registration: Australian New Zealand Clinical Trials Registry ACTRN12610000224022 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. 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. 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. Refereed/Peer-reviewed

Background This report presents the initial results of the first Epidemiological Catchment Area Study in mental health in Canada. Five neighbourhoods in the South-West sector of Montreal, with a population of 258,000, were under study. The objectives of the research program were: 1) to assess the prevalence and incidence of psychological distress, mental disorders, substance abuse, parasuicide, risky behaviour and quality of life; 2) to examine the links and interactions between individual determinants, neighbourhood ecology and mental health in each neighbourhood; 3) to identify the conditions facilitating the integration of individuals with mental health problems; 4) to analyse the impact of the social, economic and physical aspects of the neighbourhoods using a geographic information system. 5) to verify the adequacy of mental health services. Method A longitudinal study in the form of a community survey was used, complemented by focused qualitative sub-studies. The longitudinal study included a randomly selected sample of 2,433 individuals between the ages of 15 and 65 in the first wave of data collection, and three other waves are projected. An overview of the methods is presented. Results The prevalence of psychological distress, mental disorders and use of mental health services and their correlates are described for the first wave of data collection. Conclusion Several vulnerable groups and risk factors related to socio-demographic variables have been identified such as: gender, age, marital status, income, immigration and language. These results can be used to improve treatment services, prevention of mental disorders, and mental health promotion.

Little is known about the situational contexts in which individuals consume processed sources of dietary sugars. This study aimed to describe the situational contexts associated with the consumption of sweetened food and drink products in a Catholic Middle Eastern Canadian community. A two-stage exploratory sequential mixed-method design was employed with a rationale of triangulation. In stage 1 (n = 62), items and themes describing the situational contexts of sweetened food and drink product consumption were identified from semi-structured interviews and were used to develop the content for the Situational Context Instrument for Sweetened Product Consumption (SCISPC). Face validity, readability and cultural relevance of the instrument were assessed. In stage 2 (n = 192), a cross-sectional study was conducted and exploratory factor analysis was used to examine the structure of themes that emerged from the qualitative analysis as a means of furthering construct validation. The SCISPC reliability and predictive validity on the daily consumption of sweetened products were also assessed. In stage 1, six themes and 40-items describing the situational contexts of sweetened product consumption emerged from the qualitative analysis and were used to construct the first draft of the SCISPC. In stage 2, factor analysis enabled the clarification and/or expansion of the instrument's initial thematic structure. The revised SCISPC has seven factors and 31 items describing the situational contexts of sweetened product consumption. Initial validation of the instrument indicated it has excellent internal consistency and adequate test-retest reliability. Two factors of the SCISPC had predictive validity for the daily consumption of total sugar from sweetened products (Snacking and Energy demands) while the other factors (Socialization, Indulgence, Constraints, Visual Stimuli and Emotional needs) were rather associated to occasional consumption of these products. Refereed/Peer-reviewed

Background Aboriginal Australians suffer from poorer overall health compared to the general Australian population, particularly in terms of cardiovascular disease and prognosis following a cardiac event. Despite such disparities, Aboriginal Australians utilise health care services at much lower rates than the general population. Improving health care utilisation (HCU) among Aboriginal cardiac patients requires a better understanding of the factors that constrain or facilitate use. The study aimed to identify ecological factors influencing health care utilisation (HCU) for Aboriginal cardiac patients, from the time of their cardiac event to 6–12 months post-event, in central Australia. Methods This qualitative descriptive study was guided by an ecological framework. A culturally-sensitive illness narrative focusing on Aboriginal cardiac patients’ “typical” journey guided focus groups and semi-structured interviews with Aboriginal cardiac patients, non-cardiac community members, health care providers and community researchers. Analysis utilised a thematic conceptual matrix and mixed coding method. Themes were categorised into Predisposing, Enabling, Need and Reinforcing factors and identified at Individual, Interpersonal, Primary Care and Hospital System levels. Results Compelling barriers to HCU identified at the Primary Care and Hospital System levels included communication, organisation and racism. Individual level factors related to HCU included language, knowledge of illness, perceived need and past experiences. Given these individual and health system barriers patients were reliant on utilising alternate family-level supports at the Interpersonal level to enable their journey. Conclusion Aboriginal cardiac patients face significant barriers to HCU, resulting in sub-optimal quality of care, placing them at risk for subsequent cardiovascular events and negative health outcomes. To facilitate HCU amongst Aboriginal people, strategies must be implemented to improve communication on all levels and reduce systemic barriers operating within the health system.

Introduction Long-term measures to reduce tobacco consumption in Australia have had differential effects in the population. The prevalence of smoking in Aboriginal peoples is currently more than double that of the non-Aboriginal population. Aboriginal Health Workers are responsible for providing primary health care to Aboriginal clients including smoking cessation programs. However, Aboriginal Health Workers are frequently smokers themselves, and their smoking undermines the smoking cessation services they deliver to Aboriginal clients. An understanding of the barriers to quitting smoking experienced by Aboriginal Health Workers is needed to design culturally relevant smoking cessation programs. Once smoking is reduced in Aboriginal Health Workers, they may then be able to support Aboriginal clients to quit smoking. Methods We undertook a fundamental qualitative description study underpinned by social ecological theory. The research was participatory, and academic researchers worked in partnership with personnel from the local Aboriginal health council. The barriers Aboriginal Health Workers experience in relation to quitting smoking were explored in 34 semi-structured interviews (with 23 Aboriginal Health Workers and 11 other health staff) and 3 focus groups (n = 17 participants) with key informants. Content analysis was performed on transcribed text and interview notes. Results Aboriginal Health Workers spoke of burdensome stress and grief which made them unable to prioritise quitting smoking. They lacked knowledge about quitting and access to culturally relevant quitting resources. Interpersonal obstacles included a social pressure to smoke, social exclusion when quitting, and few role models. In many workplaces, smoking was part of organisational culture and there were challenges to implementation of Smokefree policy. Respondents identified inadequate funding of tobacco programs and a lack of Smokefree public spaces as policy level barriers. The normalisation of smoking in Aboriginal society was an overarching challenge to quitting. Conclusions Aboriginal Health Workers experience multilevel barriers to quitting smoking that include personal, social, cultural and environmental factors. Multidimensional smoking cessation programs are needed that reduce the stress and burden for Aboriginal Health Workers; provide access to culturally relevant quitting resources; and address the prevailing normalisation of smoking in the family, workplace and community.

Background Aboriginal Health Workers (AHWs) have a mandate to deliver smoking cessation support to Aboriginal people. However, a high proportion of AHWs are smokers and this undermines their delivery of smoking cessation programs. Smoking tobacco is the leading contributor to the burden of disease in Aboriginal Australians and must be prevented. Little is known about how to enable AHWs to quit smoking. An understanding of the factors that perpetuate smoking in AHWs is needed to inform the development of culturally relevant programs that enable AHWs to quit smoking. A reduction of smoking in AHWs is important to promote their health and also optimise the delivery of smoking cessation support to Aboriginal clients. Methods We conducted a fundamental qualitative description study that was nested within a larger mixed method participatory research project. The individual and contextual factors that directly or indirectly promote (i.e. perpetuate) smoking behaviours in AHWs were explored in 34 interviews and 3 focus groups. AHWs, other health service staff and tobacco control personnel shared their perspectives. Data analysis was performed using a qualitative content analysis approach with collective member checking by AHW representatives. Results AHWs were highly stressed, burdened by their responsibilities, felt powerless and undervalued, and used smoking to cope with and support a sense of social connectedness in their lives. Factors directly and indirectly associated with smoking were reported at six levels of behavioural influence: personal factors (e.g. stress, nicotine addiction), family (e.g. breakdown of family dynamics, grief and loss), interpersonal processes (e.g. socialisation and connection, domestic disputes), the health service (e.g. job insecurity and financial insecurity, demanding work), the community (e.g. racism, social disadvantage) and policy (e.g. short term and insecure funding). Conclusions An extensive array of factors perpetuated smoking in AHWs. The multitude of personal, social and environmental stressors faced by AHWs and the accepted use of communal smoking to facilitate socialisation and connection were primary drivers of smoking in AHWs in addition to nicotine dependence. Culturally sensitive multidimensional smoking cessation programs that address these factors and can be tailored to local needs are indicated.

Background Participatory Research (PR) entails the co-governance of research by academic researchers and end-users. End-users are those who are affected by issues under study (e.g., community groups or populations affected by illness), or those positioned to act on the knowledge generated by research (e.g., clinicians, community leaders, health managers, patients, and policy makers). Systematic reviews assessing the generalizable benefits of PR must address: the diversity of research topics, methods, and intervention designs that involve a PR approach; varying degrees of end-user involvement in research co-governance, both within and between projects; and the complexity of outcomes arising from long-term partnerships. Methods We addressed the above mentioned challenges by adapting realist review methodology to PR assessment, specifically by developing inductively-driven identification, selection, appraisal, and synthesis procedures. This approach allowed us to address the non-uniformity and complexity of the PR literature. Each stage of the review involved two independent reviewers and followed a reproducible, systematic coding and retention procedure. Retained studies were completed participatory health interventions, demonstrated high levels of participation by non-academic stakeholders (i.e., excluding studies in which end-users were not involved in co-governing throughout the stages of research) and contained detailed descriptions of the participatory process and context. Retained sets are being mapped and analyzed using realist review methods. Results The librarian-guided search string yielded 7,167 citations. A total of 594 citations were retained after the identification process. Eighty-three papers remained after selection. Principle Investigators (PIs) were contacted to solicit all companion papers. Twenty-three sets of papers (23 PR studies), comprising 276 publications, passed appraisal and are being synthesized using realist review methods. Discussion The systematic and stage-based procedure addressed challenges to PR assessment and generated our robust understanding of complex and heterogeneous PR practices. To date, realist reviews have focussed on evaluations of relatively uniform interventions. In contrast our PR search yielded a wide diversity of partnerships and research topics. We therefore developed tools to achieve conceptual clarity on the PR field, as a beneficial precursor to our theoretically-driven synthesis using realist methods. Findings from the ongoing review will be provided in forthcoming publications.

This review establishes the relevance and frames the relationship of environmental factors to cardiometabolic risk factors and disease in Aboriginal populations. Environmental factors operate at the level of communities or populations. They include contextual measures of places and compositional measures of populations which together constitute "risk conditions" affecting individual risk factors. Environmental factors have been implicated by contrasting Aboriginal and non-Aboriginal populations in cardiometabolic risk factors and outcomes, or by geographic contrasts of Aboriginal populations in remote, rural and urban regions. It is unclear whether heterogeneity in contextual or compositional factors between and within Aboriginal populations is associated with heterogeneity in cardiometabolic risk factors and outcomes. Empirical literature that links environmental factors and cardiometabolic outcomes in Aboriginal populations is critically reviewed for three postulated pathways of influence: (1) behaviour; (2) psychosocial factors; and (3) stress response axes. These pathways, represented as interdependent, can explain how and why environments are associated with cardiometabolic outcomes. The need remains, however, to develop a robust quantitative evidence base in cardiometabolic research aimed at enhancing knowledge of the specific environmental factors related to the cardiometabolic health of Aboriginal populations as well as explicating the underlying mechanisms by which environmental risk conditions ‘get under the skin'.

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. Refereed/Peer-reviewed

BACKGROUND:Indigenous peoples in Australia are disadvantaged on all markers of health and social status across the life course. Psychosocial factors are implicated in the aetiology of chronic diseases and in pathways underpinning social health disparities. Minimal research has investigated psychosocial factors and health in Indigenous peoples. This study evaluated associations between mastery, perceived stress, and health-related behaviour for a remote Indigenous population in Australia.METHODS:Complete data on mastery (the degree to which individuals feel in control of their lives), perceived stress, physical activity, and fruit and vegetable consumption were obtained for 177 participants in a community-based chronic disease risk factor survey. Psychosocial questionnaires were completed as an option during community screening (response rate = 61.9%). Extensive consultation facilitated the cross-cultural adaptation of measures.RESULTS:Mastery was inversely correlated with perceived stress measures (p < 0.009): recent stress, r = -0.47; chronic stress, r = -0.41; and youth stress, r = -0.30. Relationships between mastery and behaviour varied according to age group (, Affiliation: Mark Daniel : Département de médecine sociale et préventive, Faculté de médecine, Université de Montréal

Objectives. Report the 8-year impact on body size, physical activity, and diet of a community-based diabetes prevention program for elementary-school children in a Kanien'kehá:ka (Mohawk) community in Canada.Methods. Follow-up (1994–1996) of subjects in the intervention and comparison community and repeat cross-sectional measurements in the intervention community alone from 1994 to 2002. Measures included triceps and subscapular skinfold thicknesses, body mass index (BMI), weekly number of 15-minute episodes of physical activity, run/walk test times, television watching, and consumption of sugared foods, fatty foods, and fruits and vegetables.Results. The longitudinal data of 1994–1996 showed some early positive effects of the program on skinfold thickness but not on BMI, physical activity, fitness, or diet. Repeat cross-sectional measures from 1994 to 2002 showed increases in skinfold thickness and BMI. Physical activity, fitness, and television watching showed favorable trends from 1994 to 1999 that were not sustained in 2002. Key high-fat and high-sugar foods consumption decreased, as did consumption of fruits and vegetables.Conclusions. Although early results showed some successes in reducing risk factors for type 2 diabetes, these benefits were not maintained over 8 years.

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.

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

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.