Search

The health of Indigenous Australians is far poorer than non-Indigenous Australians, including an excess burden of infectious diseases. The health effect of built environmental (BE) features on Indigenous communities receives little attention. This study's objective was to determine associations between BE features and infectious disease incidence rates in remote Indigenous communities in the Northern Territory (NT), Australia. Remote Indigenous communities ( n = 110) were spatially joined to 93 Indigenous Locations (ILOC). Outcomes data were extracted (NT Notifiable Diseases System) and expressed as ILOC-specific incidence rates. Counts of buildings were extracted from community asset maps and grouped by function. Age-adjusted infectious disease rates were dichotomised, and bivariate binomial regression used to determine the relationships between BE variables and infectious disease. Infrastructure Shelter BE features were universally associated with significantly elevated disease outcomes (relative risk 1.67 to 2.03). Significant associations were observed for Services, Arena, Community, Childcare, Oval, and Sports and recreation BE features. BE groupings associated with disease outcomes were those with communal and/or social design intent or use. Comparable BE groupings without this intent or use did not associate with disease outcomes. While discouraging use of communal BE features during infectious disease outbreaks is a conceptually valid countermeasure, communal activities have additional health benefits themselves, and infectious disease transmission could instead be reduced through repairs to infrastructure, and more infrastructure. This is the first study to examine these associations simultaneously in more than a handful of remote Indigenous communities to illustrate community-level rather than aggregated population-level associations.

Introduction: Indigenist evaluation is emergent in Australia; the premise of which is that evaluations are undertaken for Indigenous, by Indigenous and with Indigenous people. This provides opportunities to develop new models and approaches. Exploring a collective capability approach could be one way to inform an Indigenist evaluation methodology. Collective capability suggests that a base of skills and knowledges exist, and when these assets come together, empowerment and agency emerge. However, collective capability requires defining as it is not common terminology in population health or evaluation. Our aim is to define the concept of collective capability in Indigenist evaluation in Australia from an Australian Indigenous standpoint., Methods and Analysis: A modified Rodgers' evolutionary concept analysis will be used to define collective capability in an Australian Indigenous evaluation context, and to systematically review and synthesise the literature. Approximately 20 qualitative interviews with Aboriginal and Torres Strait Islander knowledge holders will clarify the meaning of collective capability and inform appropriate search strategy terms with a consensus process then used to code the literature. We will then systematically collate, synthesise and analyse the literature to identify exemplars or models of collective capability from the literature., Ethics and Dissemination: The protocol has approval from the Australian Institute of Aboriginal and Torres Strait Islander Studies Ethics Committee, approval no. EO239-20210114. All knowledge holders will provide written consent to participate in the research. This protocol provides a process to developing a concept, and will form the basis of a new framework and assessment tool for Indigenist evaluation practice. The concept analysis will establish definitions, characteristics and attributes of collective capability. Findings will be disseminated through a peer-reviewed journal, conference presentations, the project advisory group, the Thiitu Tharrmay reference group and Aboriginal and Torres Strait Islander community partners supporting the project., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

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.

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.

The health of Indigenous Australians is dramatically poorer than that of the non-Indigenous population. Amelioration of these differences has proven difficult. In part, this is attributable to a conceptualisation which approaches health disparities from the perspective of individual-level health behaviours, less so the environmental conditions that shape collective health behaviours. This ecological study investigated associations between the built environment and cardiometabolic mortality and morbidity in 123 remote Indigenous communities representing 104 Indigenous locations (ILOC) as defined by the Australian Bureau of Statistics. The presence of infrastructure and/or community buildings was used to create a cumulative exposure score (CES). Records of cardiometabolic-related deaths and health service interactions for the period 2010-2015 were sourced from government department records. A quasi-Poisson regression model was used to assess the associations between built environment "healthfulness" (CES, dichotomised) and cardiometabolic-related outcomes. Low relative to high CES was associated with greater rates of cardiometabolic-related morbidity for two of three morbidity measures (relative risk (RR) 2.41-2.54). Cardiometabolic-related mortality was markedly greater (RR 4.56, 95% confidence interval (CI), 1.74-11.93) for low-CES ILOCs. A lesser extent of "healthful" building types and infrastructure is associated with greater cardiometabolic-related morbidity and mortality in remote Indigenous locations. Attention to environments stands to improve remote Indigenous health., Competing Interests: The authors declare no conflicts of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.

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.

Objective: The mixed methods appraisal tool (MMAT) was developed for critically appraising different study designs. This study aimed to improve the content validity of three of the five categories of studies in the MMAT by identifying relevant methodological criteria for appraising the quality of qualitative, survey, and mixed methods studies., Study Design and Setting: First, we performed a literature review to identify critical appraisal tools and extract methodological criteria. Second, we conducted a two-round modified e-Delphi technique. We asked three method-specific panels of experts to rate the relevance of each criterion on a five-point Likert scale., Results: A total of 383 criteria were extracted from 18 critical appraisal tools and a literature review on the quality of mixed methods studies, and 60 were retained. In the first and second rounds of the e-Delphi, 73 and 56 experts participated, respectively. Consensus was reached for six qualitative criteria, eight survey criteria, and seven mixed methods criteria. These results led to modifications of eight of the 11 MMAT (version 2011) criteria. Specifically, we reformulated two criteria, replaced four, and removed two. Moreover, we added six new criteria., Conclusion: Results of this study led to improve the content validity of this tool, revise it, and propose a new version (MMAT version 2018)., (Copyright © 2019 The Authors. Published by Elsevier Inc. All rights reserved.)

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.

Objectives: To outline contemporary and novel developments for the presentation and reporting of syntheses of qualitative, implementation, and process evaluation evidence and provide recommendations for the use of reporting guidelines., Study Design and Setting: An overview of reporting guidelines for qualitative, implementation, and process evaluation evidence syntheses drawing on current international literature and the collective expert knowledge of the Cochrane Qualitative and Implementation Methods Group., Results: Several reporting guidelines exist that can be used or adapted to report syntheses of qualitative, implementation, and process evaluation evidence. Methods to develop individual guidance varied. The use of a relevant reporting guideline can enhance the transparency, consistency, and quality of reporting. Guidelines that exist are generic, method specific, and for particular aspects of the reviewing process, searching., Conclusion: Caution is expressed over the potential for reporting guidelines to produce a mechanistic approach moving the focus away from the content and toward the procedural aspects of the review. The use of a reporting guideline is recommended and a five-step decision flowchart to guide the choice of reporting guideline is provided. Gaps remain in method-specific reporting guidelines such as mixed-study, implementation, and process evaluation evidence syntheses., (Copyright © 2017 Elsevier Inc. All rights reserved.)

This paper updates previous Cochrane guidance on question formulation, searching, and protocol development, reflecting recent developments in methods for conducting qualitative evidence syntheses to inform Cochrane intervention reviews. Examples are used to illustrate how decisions about boundaries for a review are formed via an iterative process of constructing lines of inquiry and mapping the available information to ascertain whether evidence exists to answer questions related to effectiveness, implementation, feasibility, appropriateness, economic evidence, and equity. The process of question formulation allows reviewers to situate the topic in relation to how it informs and explains effectiveness, using the criterion of meaningfulness, appropriateness, feasibility, and implementation. Questions related to complex questions and interventions can be structured by drawing on an increasingly wide range of question frameworks. Logic models and theoretical frameworks are useful tools for conceptually mapping the literature to illustrate the complexity of the phenomenon of interest. Furthermore, protocol development may require iterative question formulation and searching. Consequently, the final protocol may function as a guide rather than a prescriptive route map, particularly in qualitative reviews that ask more exploratory and open-ended questions., (Copyright © 2017 Elsevier Inc. All rights reserved.)

The Cochrane Qualitative and Implementation Methods Group develops and publishes guidance on the synthesis of qualitative and mixed-method implementation evidence. Choice of appropriate methodologies, methods, and tools is essential when developing a rigorous protocol and conducting the synthesis. Cochrane authors who conduct qualitative evidence syntheses have thus far used a small number of relatively simple methods to address similarly written questions. Cochrane has invested in methodological work to develop new tools and to encourage the production of exemplar reviews to show the value of more innovative methods that address a wider range of questions. In this paper, in the series, we report updated guidance on the selection of tools to assess methodological limitations in qualitative studies and methods to extract and synthesize qualitative evidence. We recommend application of Grades of Recommendation, Assessment, Development, and Evaluation-Confidence in the Evidence from Qualitative Reviews to assess confidence in qualitative synthesized findings. This guidance aims to support review authors to undertake a qualitative evidence synthesis that is intended to be integrated subsequently with the findings of one or more Cochrane reviews of the effects of similar interventions. The review of intervention effects may be undertaken concurrently with or separate to the qualitative evidence synthesis. We encourage further development through reflection and formal testing., (Copyright © 2017 Elsevier Inc. All rights reserved.)

The Cochrane Qualitative and Implementation Methods Group develops and publishes guidance on the synthesis of qualitative and mixed-method evidence from process evaluations. Despite a proliferation of methods for the synthesis of qualitative research, less attention has focused on how to integrate these syntheses within intervention effectiveness reviews. In this article, we report updated guidance from the group on approaches, methods, and tools, which can be used to integrate the findings from quantitative studies evaluating intervention effectiveness with those from qualitative studies and process evaluations. We draw on conceptual analyses of mixed methods systematic review designs and the range of methods and tools that have been used in published reviews that have successfully integrated different types of evidence. We outline five key methods and tools as devices for integration which vary in terms of the levels at which integration takes place; the specialist skills and expertise required within the review team; and their appropriateness in the context of limited evidence. In situations where the requirement is the integration of qualitative and process evidence within intervention effectiveness reviews, we recommend the use of a sequential approach. Here, evidence from each tradition is synthesized separately using methods consistent with each tradition before integration takes place using a common framework. Reviews which integrate qualitative and process evaluation evidence alongside quantitative evidence on intervention effectiveness in a systematic way are rare. This guidance aims to support review teams to achieve integration and we encourage further development through reflection and formal testing., (Copyright © 2017 Elsevier Inc. All rights reserved.)

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., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

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.)

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.

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.

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.

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: The prevalence of smoking is high in many Aboriginal Canadian communities; rates of 50% are not uncommon. Aboriginal Canadians suffer a severe burden of smoking-related disease. Research in other populations has linked depression and smoking. It is not known whether mental health or affective measures are related to smoking for any of Canada's First Nations, and this study sought to answer this question. Understanding relations between affect and smoking behaviour is requisite to mounting anti-smoking interventions., Methods: Smoking status and psychosocial measures including depression, mastery, affect balance and social support were obtained in a community-based chronic disease survey for a rural Interior Salishan First Nation in British Columbia (Plateau area). Persons surveyed were on-reserve residents (n=187), overweight (body mass index > or = 25 kg/m2), with mean age of 44.1 years (standard deviation 15.0)., Results: The prevalence of smoking was 48.1%. Adjusted for age, sex and body mass index, smokers relative to nonsmokers had higher (p<0.010) depression (mean 21.3 [CI 95%, 19.1-23.4] vs. 16.1 [14.1-18.0]) and negative affect (18.6 [14.9-22.3] vs. 11.0 [7.6-14.4]), and lower mastery (36.4 [35.5-37.3] vs. 38.1 [37.2-38.9]). A positive relationship between mastery and social support was greater for nonsmokers (p=0.046)., Conclusion: Depression and negative affect are associated with smoking among overweight persons in a rural First Nation in British Columbia. Furthermore, smoking is inversely related to mastery, and this relation varies with social support. Longitudinal study is required to determine whether smoking influences mental health and mastery, or the reverse.

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.

Objective: To develop a theoretical framework of youth empowerment in the context of a participatory community health promotion intervention, a longitudinal qualitative study was conducted., Methods: Individual and group interviews, documents, and observations were analyzed using the constant comparative method and theoretical sampling., Results: Practitioners created an environment conducive to adolescents' taking responsibility for their quality-of-life issues by welcoming and enabling youth. Power was transferred to youth as responsibility for voicing, decision making, and action. This led to positive changes in youth development and their social integration into community., Conclusion: Empowerment emerged as a transactional partnering process between adults and youth.