Health promotion

This section is a guide to available information about Australian Indigenous health promotion. It is an attempt to bring together the information that exists in the area and we welcome input from those working in the field. Some sub-sectionsare still being developed and we hope to place more material in these areas shortly. Many effective programs are being run that have not yet been documented, but the number of recent conference papers being presented on work in the area is increasing and indicates that there are many successful programs. The initial sub-section focuses on health promotion generally and is followed by a summary of developments in Indigenous health promotion. Both summaries will be subjected to peer review by our consultants.

The WA Indigenous Health Promotion Network (WAIHPN), which includes Indigenous and non-Indigenous people involved in Indigenous health promotion, aims to facilitate the sharing of relevant information and knowledge with the ultimate goal of improving the health of Indigenous Western Australians. The Western Australian Indigenous Health Promotion Network website was launched in 2005 view website.

 

Summary of developments in Indigenous health promotion

Introduction

Health promotion has been described as:

the process of enabling people to increase control over, and to improve their health. To reach a state of complete physical, mental and social wellbeing an individual or group must be able to identify and realise aspirations, to satisfy needs and to change or cope with the environment. [1]

or, more simply, as

the combination of educational and environmental supports for actions and conditions of living conducive to health. [2]
Health promotion includes social, environmental and political processes that encourage individuals, groups of people and populations to increase control over, and to improve their health. Health promotion draws on a number of disciplines, including public health, political science, education, communication, anthropology, epidemiology, sociology and psychology.

Basic principles of health promotion were included in the Ottawa Charter (view the Ottawa Charter - WHO), which was adopted at the first international health promotion conference [1]. The Charter provided a statement of action for health promotion and guidance in defining action areas. The five priority health promotion action areas identified were:

  • building healthy public policy;
  • creating supportive environments for health;
  • strengthening community action for health;
  • developing personal skills; and
  • re-orienting health services.

For a history of the development of health promotion view the ACT Health Promotion website.

Health promotion for Indigenous people needs to take into account culture, diversity within the population; socioeconomic circumstances; numerous languages and dialects, geographic location, and, importantly, the consequences of colonisation (which have impacted on the social, economic, and physical living conditions of Indigenous people) [3]. Health is viewed holistically in the Indigenous population, and is inclusive of the physical, social, emotional and cultural wellbeing of individuals and communities [4]. Relationships within the community (particularly those with elders), and spiritual connections to the land and ancestors need to be considered in the interpretation of health issues [5]. Specific health issues and their contributing factors need to be assessed in the context of Indigenous people’s lives and the disproportionate burden of disadvantage they bear compared with the non-Indigenous population.

National developments in Indigenous health promotion

In one sense, activities that promote health have been a natural part of life throughout human history. In the past the hunter gatherer lifestyle of traditional Indigenous communities would have promoted health by providing a supply of nutritious foods and ensuring adequate physical activity.

The development of formal health promotion activities is, however, fairly recent. The establishment of the World Health Organization in 1948 is seen as an important stage in this development (view webpage on ACT Health Promotion website).

In terms of Indigenous health promotion, a significant development was the Indigenous initiative in establishing community-controlled health services [6]. The operations of Aboriginal community-controlled health services (ACCHSs), the first of which was established in Redfern (Sydney) in 1971, are directed by the local community to ensure that the services are provided in a culturally appropriate manner [7] (view health policy timelines). ACCHSs liaise with governments, departments, and organisations within both Indigenous and non-Indigenous communities on matters relating to the wellbeing of Indigenous communities [8]. Actions include addressing factors in the behaviour of individuals, families and communities linked with poorer health outcomes [7]. For example, alcohol restrictions have been promoted to address misuse and healthy dietary practices have been encouraged to address unhealthy nutrition.

The employment of Aboriginal and Torres Strait Islander health workers predated the establishment of the ACCHSs (Aboriginal people, mainly women, were employed in leprosy hospitals in the Northern Territory in the 1950s and then as medical assistants in these locations [9]), but their development as a professional group really only began in the 1970s. Since that time, growing numbers of Indigenous health workers have assisted efforts to improve the health and wellbeing of individuals and communities (view health workers page).

Australian Indigenous Health Promotion Knowledge Network

It was not until 1995, however, that serious efforts were made to stimulate activities through the development of a network of Indigenous health workers involved in health promotion. In that year, the Australian Centre for Health Promotion (at the University of Sydney) convened a meeting of Indigenous health workers who had an interest in and/or experience in health promotion. The Australian Indigenous Health Promotion Network, established at that meeting, was given responsibility for implementation of an ‘Agenda for action’ (view Australian Indigenous Health Promotion Knowlege Network website). That agenda has formed the basis for the work that has been carried out by the Network since that time [10].

The Network works in a number of ways to support Indigenous people engaged in health promotion by:

  • enabling regular communication about their work;
  • advising on conferences, workshops, policy reviews and literature;
  • linking with international Indigenous health and health promotion networks;
  • facilitating professional exchange opportunities; and organising professional development opportunities.

The Network assists by identifying the education and training needs of Indigenous health promotion practitioners, researchers and policy makers [10]. It has worked with universities and colleges to develop and implement relevant professional preparation and education courses in Indigenous health and health promotion, and has supported and advised on Indigenous health promotion curriculum development. The Network provides assistance in disseminating relevant health and public policy documents. It also contributes to national debate and decision-making about infrastructure support and funding required for Indigenous health promotion, and acts as an advisory body on policy, education and work practices that improve the health status of Indigenous people.

The Network has been seen as instrumental in the health advancement of Indigenous people [11]. Achievements have included: contributing to the development of a strong Indigenous presence at national health promotion conferences; collaborating with the National Centre for Health Promotion and the Koori Centre at the University of Sydney to develop a graduate Diploma in Indigenous Health Promotion; convening a national symposium on promoting the health of Indigenous Australians; contributing to a major review of infrastructure support for Indigenous health advancement; and contributing case studies of programs that have been effective in promoting the health of Aboriginal and Torres Strait Islander people [8]. Teleconferences and meetings at conferences and workshops have led to actions to improve the knowledge, skills, and practice of Australia's Indigenous health promotion workforce.

Health Australia Review

In 1996, the Health Australia Review was undertaken by the Health Advancement Standing Committee of the National Health and Medical Research Council (NHMRC) to identify and analyse practices in health promotion [12]. It included consultation with Indigenous health workers and health administrators from government and community controlled health services. The consultation findings were outlined in the report Promoting the health of Indigenous Australians: a review of infrastructure support for Aboriginal and Torres Strait Islander health advancement. The report recommended specific steps for building the capacity of the health sector to support the work of Indigenous health personnel working in partnerships with their communities, their peers, and with the mainstream health system, to achieve improved Indigenous health.

The project coordinator for the Indigenous component, Ms Sandy Angus, identified many projects that were conducted in and with Indigenous communities around Australia to improve health [3]. Details are documented in the NHMRC report Promoting the health of Aboriginal and Torres Strait Island communities - case studies and principles of good practice, which recommended actions to improve capacity to promote the health of Indigenous people.

National Public Health Partnership Guidelines Project

More recently the National Public Health Partnership Guidelines Project has encouraged a strategic approach to the development, implementation and evaluation of public health strategies for Indigenous communities. Aimed at developing suitable guidelines, the first phase of the project was documented in the 2002 report Guidelines for the development, implementation and evaluation of national public health strategies in relation to Aboriginal and Torres Strait Islander peoples: approaches and recommendations [13]. This document reports the findings of an international and national literature review and national consultative process on issues related to the development and implementation of national public health strategies with Indigenous communities. It includes specific references to health promotion. A national workshop was convened in 2003 to consider this preliminary draft, and the second part of the project will lead to the development of a final set of guidelines.

Towards a Collaborative Centre for Aboriginal Health Promotion

Recommendations for the development of a collaborative centre for Aboriginal health promotion were initially proposed by NSW Health in the early 1990s. The establishment of such a centre would be an important contribution to the provision of infrastructure - across health and other key sectors - to support Indigenous health advancement, as recommended in the 1996 Health Australia Review [12].

In 2002, following a recommendation from the Standing Committee on Aboriginal and Torres Strait Islander Health (SCATSIH), NSW Health hosted a national consultation workshop to consider establishment of such a centre [14]. The workshop was supported and attended by representatives of the Commonwealth Department of Health and Ageing and the NSW Aboriginal Health Partnership. Also attending were key representatives working in Indigenous health promotion, general health promotion, or population health from all States and Territories. The workshop aimed at reaching consensus on best practice principles for Indigenous health promotion and building a national representative collection of case studies. It was also anticipated that recommendations could be reached on mechanisms to ensure the sustainability of case study contributions to a Collaborative Centre for Aboriginal Health Promotion.

The workshop recognised previous Indigenous health initiatives (for example the National Strategic Framework for Aboriginal and Torres Strait Islander Health view report and the quest for best practice as documented in the National Aboriginal Community Controlled Health Organisation (NACCHO) report Tobacco time for Action view report, and the NHMRC report Promoting the health of Aboriginal and Torres Strait Island communities - case studies and principles of good practice view report). It was envisaged that the outcomes of the workshop would build on and be consistent with work of the:

  • National Public Health Partnership: Guidelines for the development, implementation and evaluation of National Public Health Strategies in relation to Aboriginal and Torres Strait Islander peoples
    view report    ;
  • NSW Aboriginal Health Promotion Program: Directions Paper
    view report; and
  • Australian Indigenous HealthInfoNet
    view website.

At the workshop State and Territory representatives agreed to the Consensus Statement on Principles for Better Practice in Aboriginal Health Promotion (see below).

Following the workshop, in 2003 NSW Health and the Aboriginal Health & Medical Research Council of NSW (AHMRC) established a Collaborative Centre for Aboriginal Health Promotion as an initiative under the NSW Aboriginal Health Partnership. The mission of the Centre, which is based within the AHMRC in Redfern (Sydney), is to improve the effectiveness of Indigenous health promotion in NSW – and potentially throughout Australia. It aims to ensure a strategic approach for Indigenous health promotion by fostering leadership and coordination in key areas of capacity building, better practice, workforce development, partnerships and information systems for Indigenous health promotion at the state level.
The draft document on which establishment of the Centre was based included provision for a clearinghouse for best practice in Aboriginal health – this had been identified as a key priority for ‘increasing the effectiveness of health promotion’ in the NSW Aboriginal Health Strategic Plan. The clearinghouse’s key functions would include:

  • providing a range of quality information resources and materials on Indigenous health promotion;
  • ensuring accessibility to a diverse range of professionals and community members;
  • innovative methods of collecting, analysing and disseminating information pertaining to Indigenous health promotion; and
  • establishing formal links with other clearinghouses.

Identifying best practice in Indigenous health promotion

Existing policies, guidelines, strategic directions and other documents can guide Indigenous health promotion at State, Territory and national levels, but there is an ongoing quest for identifying best practice. This quest has been marked in recent years by a range of key initiatives and documents which have culminated thus far in the above mentioned Consensus Statement.

In 1991, work in a Kimberley injury prevention project led to the development of a model for health promotion in Indigenous communities [4]. The conceptual framework outlined three phases:

  • processes that can make people receptive to local health promotion programs (such as community consultation, identification of community health issues and developing messages that are relevant to the community);
  • development of action plans concerned with environmental and behavioural change, assisted by trained Indigenous health promotion workers; and
  • development by community groups and organisations of their own health promotion programs, with the Indigenous health workers acting in a consulting capacity.

As noted above, the 1996 report Promoting the health of Aboriginal and Torres Strait Island communities - case studies and principles of good practice examined project achievements and identified common core principles to guide good practice. Sandy Angus and Marilyn Wise summarised ‘what had been learned’ with principles emphasising:

  • identification of needs by the community;
  • pivotal roles of Indigenous health workers in working with communities to identify concerns and establish whether people want to take action; and establishment of partnerships between Indigenous health workers, communities and non-Indigenous health workers.

In 2002 the Sydney Consensus Statement on Principles for Better Practice in Aboriginal Health Promotion [14], was produced as a stand-alone document based on the national consultation workshop deliberations and subsequent comment (view report).

These principles are:

Aboriginal health promotion should acknowledge Aboriginal cultural influences and the historical, social and cultural context of communities – health promotion initiatives need to sensitively acknowledge, affirm and reflect the values of Aboriginal culture sensitively within and between communities. Initiatives that neglect the effects of history and the social environment of Aboriginal people will have limited success.

Aboriginal health promotion practice should be based on available evidence – evidence can come from a wide range of sources. Qualitative as well [as] quantitative evidence can inform practice. Decisions about the evidence on which to base practice should take account of the strengths, limitations and gaps in the available evidence.

Effective Aboriginal health promotion practice means building the capacities of the community, government, service systems, organisations and the workforce, ensuring equitable resource allocation (flexible purchaser-provider arrangements) cultural security and respect in the workplace – examples of building and strengthening capacities through effective practice could be where others agree to participate in or take on programs; where individuals, units or even government departments have greater ability to work together to solve problems; or where a process is established for routinely improving practice.

Aboriginal health promotion should ensure ongoing community involvement and consultation – Aboriginal health promotion initiatives need to have community input at all levels of program planning, implementation and evaluation. Support from the broader community and within the wider health system will impact on effective and sustainable practice.

The practical application of Aboriginal self-determination principles is fundamental in all Aboriginal health promotion planning – Aboriginal people are best placed to work consistently in partnership with relevant organisations on interventions that build community ownership and respond to the needs and motivations of the community with cultural understanding and sensitivity.

Aboriginal health promotion adheres to the holistic definition of health and acknowledges that primary health care in Aboriginal communities incorporates Aboriginal health promotion – a coordinated and proactive approach to primary health care that includes early intervention and prevention strategies will promote improved Aboriginal health and wellbeing.

The establishment of effective partnerships is required to address many of the determinants of health – many of the determinants of health are beyond the direct influence of the health sector alone. Different collaborations and partnership approaches are likely to be prerequisites for effective action to address these determinants.

Aboriginal health promotion programs should aim to be sustainable and transferable – sustainable programs will be planned and organised to incorporate rigorous evaluation throughout and be responsive to the outcomes of that evaluation. Programs that are multi-faceted and include effective evaluation and sustainability strategies will also improve the design of future programs. Involving stakeholders, in particular those who have supported similar initiatives, can positively influence the transferability of programs. Providing formal and/or informal training of people whose skills and interest will be retained can create a broader base of advocacy.

Aboriginal health promotion should demonstrate transparency of operations and accountability – visible decision-making policies and practices that are based on a sound rationale will have the capacity to take into account the complex and changing nature of Aboriginal health promotion.

Aboriginal and Islander Health Worker Journal

Over the years contributions to the Aboriginal and Islander Health Worker Journal (view website) have reflected developments in health promotion initiatives for Indigenous people. Established in 1977, this national publication has a broad readership and is an important vehicle for the communication of Indigenous health promotion information. Written in large part by Indigenous health workers for Indigenous health workers, the Journal provides an opportunity for sharing information about health issues and programs from a community perspective. It also provides a cross-cultural resource for non-Indigenous readers who work with and provide services to Indigenous communities. Each issue covers a range of topics including health promotion, primary health care, community profiles, best practice models and workforce issues. The importance of health promotion activities in the daily work of Indigenous health workers is reflected in the content of the Journal.

Comprehensive guides to articles published in the Journal have been made available in two special editions titled From Health Worker to Health Worker. The first edition covers articles published from 1997 to 1995 and the second edition from 1996 – 2003 [15, 16]. The first edition of the Indigenous Health Promotion Resources Guide was published by the Journal in 1994, with the principal aim of providing current and clear details about relevant health promotion resources available to health workers [17]. The guide is updated regularly, with the fourth and most recent edition printed in 2004.

Concluding comments

Indigenous initiatives in health promotion have led to the establishment of partnerships and networks and increased methods of disseminating health promotion information. Developments in Indigenous health promotion have also included input from Indigenous people into the planning and implementation of projects, a focus on training, the production of Indigenous specific resources and increased representation at conferences. The need for Indigenous specific health promotion techniques has been clearly identified and the quest for best practice continues.

References

1. World Health Organization (1986) Ottawa Charter for Health Promotion. Paper presented at the International Conference on Health Promotion, Ottawa:

2. Green LW, Kreuter MW (1999) Health promotion planning: an educational and ecological approach. 3rd ed. Mountain View, CA: Mayfield Publications

3. National Health and Medical Research Council (1997) Promoting the health of Aboriginal and Torres Strait Island Communities: case studies and principles of good practice. Canberra: National Health and Medical Research Council

4. National Aboriginal Health Strategy Working Party (1989) National Aboriginal health strategy. Canberra: Department of Aboriginal Affairs

5. McLennan V, Khavarpour F (2004) Culturally appropriate health promotion: its meaning and application in Aboriginal communities. Health Promotion Journal of Australia;15(3):237-239

6. Saggers S, Gray D (1991) Aboriginal health and society: the traditional and contemporary Aboriginal struggle for better health. North Sydney: Allen and Unwin

7. National Aboriginal and Torres Strait Islander Health Council (2003) National strategic framework for Aboriginal and Torres Strait Islander health: context. Canberra: National Aboriginal and Torres Strait Islander Health Council

8. Burns J, Thomson N, Brooks J, et al. (2002) Describing an iceberg from a glimpse of its tip: a summary of the literature on achievements in Aboriginal and Torres Strait Islander health. Perth: Australian Indigenous HealthInfoNet

9. Curtin Indigenous Research Centre, Centre for Educational Research and Evaluation Consortium, Jojara & Associates (nd) Training re-visions: a national review of Aboriginal and Torres Strait Islander health worker training. Perth: Curtin University

10. Australian Indigenous Health Promotion Network (2005) Australian Indigenous Health Promotion Network. Retrieved 3 from http://www.indigenoushealth.med.usyd.edu.au/

11. Angus S (1997) Building a strong voice for promoting the health of Indigenous communities. Paper presented at the Public Health Association of Australia 29th Annual Conference: Rights to Health 5-8 October, Melbourne

12. National Health and Medical Research Council (1997) Promoting the health of Indigenous Australians: a review of infrastructure support for Aboriginal and Torres Strait Islander health advancement. Canberra: National Health and Medical Research Council

13. Kimberley Aboriginal Medical Services Council, Effective Health Care Australia University of Sydney, School of Public Health and Tropical Medicine James Cook University (2002) Guidelines for the development, implementation and evaluation of national public health strategies in relation to Aboriginal and Torres Strait Islander peoples: approaches and recommendations. Melbourne: National Public Health Partnership

14. NSW Health (2002) Principles for better practice in Aboriginal health promotion: the Sydney Consensus Statement. North Sydney: NSW Health

15. Ellis R (1996) From health worker to health worker: an annotated index of Indigenous health information published in the Aboriginal and Islander Health Worker Journal 1977 - 1995. Matraville, NSW: The Aboriginal and Islander Health Worker Journal

16. Aboriginal and Health Worker Journal (2004) From health worker to health worker: an annotated index of Indigenous health information published in the Aboriginal and Islander Health Worker Journal 1996-2003. Matraville, NSW: The Aboriginal and Islander Health Worker Journal

17. Aboriginal and Islander Health Worker Journal (2004) The Indigenous health promotion resources guide. 4th ed. Sydney: Aboriginal and Islander Health Worker Journal

 

 

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Last updated: 15 January 2007