Family-centred interventions by primary healthcare ...

RESEARCH ARTICLE Open Access

Family-centred interventions by primaryhealthcare services for Indigenous earlychildhood wellbeing in Australia, Canada,New Zealand and the United States: asystematic scoping reviewJanya McCalman1*, Marion Heyeres2, Sandra Campbell2, Roxanne Bainbridge1, Catherine Chamberlain3,Natalie Strobel4 and Alan Ruben5

Abstract

Background: Primary healthcare services in Australia, Canada, New Zealand and the United States have embracedthe concept of family-centred care as a promising approach to supporting and caring for the health of youngIndigenous children and their families. This scoping review assesses the quality of the evidence base and identifiesthe published literature on family- centred interventions for Indigenous early childhood wellbeing.

Methods: Fourteen electronic databases, grey literature sources and the reference lists of Indigenous maternal andchild health reviews were searched to identify relevant publications from 2000 to 2015. Studies were included if theintervention was: 1) focussed on Indigenous children aged from conception to 5 years from the abovementionedcountries; 2) led by a primary healthcare service; 3) described or evaluated; and 4) scored greater than 50% againsta validated scale for family-centredness. The study characteristics were extracted and quality rated. Reported aims,strategies, enablers and outcomes of family-centredcare were identified using grounded theory methods.

Results: Eighteen studies (reported in 25 publications) were included. Three were randomised controlled studies;most were qualitative and exploratory in design. More than half of the publications were published from 2012 to2015. The overarching aim of interventions was to promote healthy families. Six key strategies were to: supportfamily behaviours and self- care, increase maternal knowledge, strengthen links with the clinic, build the Indigenousworkforce, promote cultural/ community connectedness and advocate for social determinants of health. Fourenablers were: competent and compassionate program deliverers, flexibility of access, continuity and integration ofhealthcare, and culturally supportive care. Health outcomes were reported for Indigenous children (nutritionalstatus; emotional/behavioural; and prevention of injury and illness); parents/caregivers (depression and substanceabuse; and parenting knowledge, confidence and skills); health services (satisfaction; access, utilization and cost) andcommunity/cultural revitalisation.

Discussion and conclusion: The evidence for family-centred interventions is in the early stages of development, butsuggests promise for generating diverse healthcare outcomes for Indigenous children and their parents/caregivers, aswell as satisfaction with and utilisation of healthcare, and community/cultural revitalisation. Further research pertainingto the role of fathers in family-centred care, and the effects and costs of interventions is needed.

Keywords: Family-centred, Patient-centred, Indigenous, Maternal and child health, Health outcomes

* Correspondence: [email protected] Queensland University, Cairns, AustraliaFull list of author information is available at the end of the article

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

McCalman et al. BMC Pregnancy and Childbirth (2017) 17:71 DOI 10.1186/s12884-017-1247-2

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BackgroundPrimary healthcare services have embraced the conceptof family-centred models of care as one approach toimprove health and preventive services for Indigenouschildren [1–3]. Family-centred approaches differ fromtraditional maternal and child healthcare which focus onthe management of individual women’s pregnancies andinfants’ health and development at healthcare clinics.Instead, family-centred care approaches provide supportand care for the whole family, their lives and wellbeingconcerns, often at the family’s home.This scoping review was conducted to inform the

development for a Cochrane review protocol [3] bysystematically searching, selecting and synthesizing existingknowledge to map key concepts, types of evidence, andgaps in research about family-centred healthcare [4]. Assuggested by Dijkers [5], assessments of the quality of theprimary studies are included to provide confidence that theimplications of the review for policy, practice or patientsare based on high quality research. The research questionwas: What is thecurrent evidence base for the impact offamily-centred interventions on Indigenous earlychildhoodhealth? Both the Cochrane and this scoping review werecontracted by a Queensland regional Indigenous com-munity controlled health service, Apunipima Cape YorkHealth Council, to inform the implementation of theirfamily-centred Baby One Program (Bainbridge R, McCal-man J, Campbell C, Redman-MacLaren M, Vine K, CanutoK, Sewter J, MacDonald M: Growing a relational and re-sponsive family health promotion program: A groundedtheory evaluation of the Baby One Program, inpreparation).In mainstream populations, many health care pro-

viders now recognise family-centred care and the relatedconcept of patient-centred care as integral to patienthealth, satisfaction, and health care quality, and considerthem to be the standard of child health care [6]. For ex-ample, the US Healthy People 2020 plan for childrenrecommends that children with special health care needsshould receive care in a “family-centred, comprehensive,coordinated system” [7]. There is evidence from main-stream settings that family-centred interventions haveresulted in decreased depression rates and burden incarers, improved quality of life for the entire family andsatisfaction with care, as well as greater health serviceeffectiveness and efficiency with reduced cost [8].The need for improved child healthcare for Indigenous

populations is evidenced by persistent disparities in childhealth equity in Australia, Canada, New Zealand and theUnited States. Mortality rates are higher in the four coun-tries for all Indigenous infants except Native Hawaiians;there are generally fewer children born with normal birth-weights (between 2500 and 4500 g); and childhood obesityrates are considerably higher for Indigenous than thegeneral populations in each of these countries [1]. These

disparities reflect the shared legacy of the impacts ofcolonisation in these countries; whereby exclusionarysocial policies have to varying degrees disrupted familyrelations, continuity and functioning [9].Many Indigenous families deal with ongoing stressors,

which can manifest inpsychological distress, grief, smokingand alcohol and drug misuse, mental illnesses, and/or vio-lence; and thus their ability to nurture children [9]. In turn,families can experience issues such as lack of food security,child neglect, and the removal of children [10]. However,Indigenous families also commonly experience strengths,such as strong bonding capital associated with their inclu-sion of members of their extended families, and the influ-ence of traditional cultural norms on child rearing practices[9]. These strengths provide opportunity upon which en-gagement in health promoting family-centred approacheswith services can be built to support improvements both tofamily lifestyle factors but also on the upstream social deter-minants of Indigenous childrens’ health and wellbeing [9].Primary health care services in Indigenous communities,

which are increasingly managed and delivered by Indigen-ous community controlled health services, have takenopportunities to develop and implement family-centred in-terventions to improve Indigenous child health. By ensuringthat care is planned and implemented around the wholefamily, family-centred interventions have the potential torecognise and support Indigenous family functioning, thatis, their communication, maintenance of relationships inhealthy ways, decision making and problem solving [11].Health services can also advocate to address system barriersto improved family health, such as for education, training,employment, and to child protection agencies.There are differing definitions for family-centred health-

care, and consequently various approaches. Nixon [12] de-fined the delivery of family-centred care by health servicesas “a way of caring for children and their families withinhealth services which ensures that care is planned aroundthe whole family, not just the individual child/person, andin which all the family members are recognised as carerecipients”. Griew, Tilton, and Stewart [13] proposed abroader two-part definition of Indigenous family-centredhealthcare as: 1) movingbeyond providing care to theindividual patient, to seeing them as being embedded in afamily and providing services on that basis; and 2) taking alife course approach, which, without neglecting adulthealth, focused specific attention on establishing early liferesilience and advantages through an emphasis on childdevelopment. This paper reviews the state and quality ofthe evidence for family-centred healthcare deliveredthrough primaryhealthcare services for Indigenous children(from conception to 5 years). The review objectives were:

1) Outline the extent of the current evidence base forfamily-centred interventions by primary healthcare

McCalman et al. BMC Pregnancy and Childbirth (2017) 17:71 of 21

services for Indigenous Australian, Canadian, NewZealander or United States early childhood wellbeing;

2) Examine the conditions which enable primaryhealthcare services to implement family centredinterventions, and the strategies they use to do so;

3) Describe the outcomes of family-centred interventionsfor Indigenous early childhood wellbeing.

MethodsInclusion/Exclusion criteriaStudies were included in this scoping review only if theywere published in English from 1 January 2000 to 31December 2015 inclusive. The start date of the reviewwas taken from 2000 when the US formally recognisedpatient-centred care as a healthcare standard [14]. Publi-cations were also included only if the study met each ofthe following four criteria:

1. Participants were Indigenous Australian, Canadian,New Zealander or United States children aged fromconception to five years who received family-centredcare. A child was considered to be Indigenous ifthey were identified by the family as Indigenous(one parent may have been non-Indigenous);‘Indigenous’ was defined using the United Nationsdefinition of self- identification and acceptance bythe community as a member [2].

2. Evaluated or described a family centred interventionor theorised a family centred healthcare model.We used Nixon’s [12] definition of family-centredhealthcare and included: a) environmentalinterventions that maximise parental involvementand enhance child health or wellbeing;b) communication interventions that include parents/caregivers in collaborative care pathways, and/orreorganisation of health care to provide continuity ofcarers; c) educational interventions for parents/caregivers or staff; d) counselling interventions suchas brief interventions, home visiting and otherapproaches; and/or e) family support interventionssuch as flexible charging schemes for poor families,referrals to other community services,parent-to-parent support [15].We included pregnancycare models only if the intervention continued beyondthe standard postpartum period of six weeks to atleast three months.

3. Intervention scored greater than 26/52 points (50%)against a validated scale for family-centredness[15, 16]. The scale incorporated 13 criteria, clusteredunder three concepts: 1) family as a constant (familyas a constant in child’s life, recognising familystrengths, collaboration between parents/caregiversand professionals, needs-based family support,flexible provision of health care, sharing information

with families); 2) culturally responsive (culturallycompetent health care, respecting family diversity,providing financial support); 3) supporting familyindividuality & need for different types of familysupport (respecting family coping methods,providing emotional support, family-to-familysupport, attending to the developmental needs ofchildren and families). Each criteria were scoredfrom zero (no evidence that the author(s) addressed,endorsed, or advocated adoption of adherence to theelements of family centred care either implicitly orexplicitly) to four (numerous instances of explicitevidence that the author(s) advancedadoption orsupport of the elements of family-centred care).

4. Intervention was led by a primary healthcare service,defined broadly as healthcare providers involved inproviding primary healthcare for Indigenous children.

Search strategyIn consultation with an expert librarian (KK), a four-stepsearch strategy was implemented. Step one comprised asearch of 14 electronic databases: MEDLINE, PsycINFO,CINAHL, Informit, Indigenous Australia, Indigenous Stud-ies Bibliography, AIATSIS, ATSIHealth, APAIS- ATSIS,FAMILY-ATSIS, Informit Indigenous Collection, CampbellLibrary, Cochrane Library, and Sociological Abstracts.MESH headings included family or parents or infant ornewborn or legal guardians or pregnancy, AND child healthservices or Maternal Health Services or Maternal-ChildNursing or Family Health or Midwifery or Family Practiceor Primary Health Care or General Practice or Delivery ofHealth Care or Patient-Centered Care or Health Promotionor Patient Care Planning AND Oceanic Ancestry GroupOR American Native Continental Ancestry Group. Steptwo comprised searches of the grey literature through fiveclearinghouses or websites of relevant organisations in eachof the four countries: Australian Indigenous HealthInfoNet, Australian Institute of Family Studies, IndigenousKnowledge Network for Infant, Child and Family Health(Canada), Li Ka Shing database at St. Michael’s Hospital(Canada), and New Zealand Social Policy Evaluation andResearch Unit. Search terms were: family-centred careAND children OR infant OR maternity OR trimester. Stepthree comprised a search of the reference lists of Indigen-ous maternal and child health systematic reviews. In stepfour, the authors of this study also drew on their knowledgeof family-centred interventions.

Identification, screening and inclusion of publicationsThe combined searches were imported into a biblio-graphic citation management software, EndNote X7 withduplicates removed. Titles and abstracts of the remainingpublication titles and abstracts were screened by oneauthor (MH). A second author (JM) retrieved and


screened titles and abstracts of the remaining publications;those which did not meet inclusion criteria were excluded.The full texts of the remaining publications were retrievedand screened by blinded reviewers (RB, SC, CC, MH, JM,AR) and independent reviewers from Apunipima CapeYork Health Council and Centre for Research Excellencefor Improving Health Services for Aboriginal and TorresStrait Islander Children (ISAC) (KE, RM, MRM, LS, NS,KT, MW). Inconsistencies in reviewer assessments wereresolved by consensus.

Data extraction & analysisThe publications were grouped together under the namefor the study. Data were extracted from the full texts forpublication authorship, publication year, study design,year/s of data collection and outcome assessmentinterval, study setting, population and sample size. Thequality of included quantitative studies was assessed byblinded reviewers (SC and CC) using the Effective PublicHealth Practice Project quality assessment tool [17].Qualitative studies were assessed by blinded reviewers(MH and JM) using the Critical Appraisal SkillsProgramme quality assessment tool [18]. The costingstudy was assessed by a health economist (IK) andauthor (JM) using the Joanna Briggs Institute criticalappraisal checklist for economic evaluations.The publications were then imported into NVIVO soft-

ware and coded (by MH). Grounded theory methods wereused to map the strategies and outcomes of family-centredinterventions, as well as the contexts and conditions underwhich they develop [19]. Grounded theory methods arewell suited to conducting exploratory scoping reviews,especially in areas like family-centred interventions forIndigenous early childhood health, which is complex andhas not been reviewed comprehensively before [19].We started by coding the studies (seven publications)

with the strongest study designs; then continued to codeand compare the concepts in the remaining studies [19].As we progressively coded and compared the papers, wefound common or similar groups of concepts that werethen recoded as higher order categories [19]. For ex-ample, across diverse studies, we identified strategies ofproviding subsidised fruit and vegetables; providing dailyhot nutritious lunches, food coupons and hampers andnutritional supplements. We coded this concept as“augmenting diet”. As more papers were coded, similarconcepts were identified, such as providing oral healthproducts; and providing safe sleeping baskets. Conse-quently, we regrouped and re-categorised the earliercode as “value-adding to health through products”. Axialcoding was then used to sort which of the categoriesrepresented the aim, contexts, conditions, strategies andoutcomes of the family- centred interventions and toidentify the interrelations between these [20]. Through

axial coding, for example, “value-adding to healththrough products” became part of a core strategy titled“supporting family behaviours and self-care”. These analyticcoding steps did not occur in a lineal order as describedhere, but were performed interactively, revisiting and refin-ing concepts and categories as new insights occurred [19].

ResultsA Preferred Reporting Items for Systematic Reviews andMeta-Analyses (PRISMA) flowchart is presented at Fig. 1[21]. The process of identification, screening and inclusionof publications resulted in 18 included studies (25 publica-tions). One study of the US Family Spirit intervention wasreported in five publications [22–26]; the Australian BabyBasket program in three publications [27–29], the AustralianTriple P parenting study intwo publications [30, 31]; andthe remaining studies had one publication each.

Characteristics of studiesThirteen of the included 25 publications (52%) were pub-lished in the last four years (2012–2015). Eleven of the 18studies were Australian (61%); three Canadian (17%); onefrom New Zealand (6%); and three from the USA (17%).Only 13/18 studies stated their setting; these being spreadfairly evenly across urban (5/13 or 38%), rural (4/13 or31%) and remote areas (4/13 or 31%) (Table 1).Twelve/18 studies reported more than one study

population. The majority of studies targeted expectantwomen or new mothers. In order of frequency, other cli-ent groups were: Indigenous children, parents/caregiversand other family members and other community mem-bers and stakeholders. Program deliverers, in order offrequency, were: Indigenous health paraprofessionals/workers, senior/Elder women who provided educationor support, other health practitioners, senior/Elder men,and partnerships withresearchers. This diversity wasrelated to the inclusivity of many family-centred ap-proaches and the varied modes of their delivery.

Study designThere were three/18 randomised controlled studies (17%),one controlled before and after study (5%) and one mixedmethod evaluation (5%) to test the impact of family-centred interventions on the quality and effectiveness ofcare. However, the remaining 13/18 studies (72%) werenon-comparison studies, including three uncontrolled be-fore and after studies, seven exploratory qualitative studiestwo program descriptions and a protocol for a longitudinalstudy (Fig. 2).

Study qualityOnly one/18 studies was rated of strong quality [22–26](Table 1). This study randomised 322 participants to theUS Family Spirit intervention or optimised standard


care, and evaluated outcomes at different time pointsusing validated measurement tools. The other assessablestudies were of moderate (7/18) moderate/weak (1/18),or weak (6/18) quality, with lack of consistently strongmethodology across the majority of assessed criteria.The quality of two program descriptions and one studyprotocol were not assessed.

Key elements of family-centred interventionsThe aims, strategies, conditions and outcomes of family-centred care reported in each study are summarised inTable 2, where ✓ denotes evidence that the author(s) ad-vanced adoption or support of the element of family-centred care, ~ denotes an implicit or inferred referenceconsistent with the intent of that element; and X denotesno evidence for that element of family-centred care.

Aim of family-centred interventionsThe aim of study interventions was to promote healthyfamilies; that is, to enable families to increase controlover and to improve their health. In 14/18 studies (78%),

this aim was explicitly reported [22–42], and in the otherfour, it was inferred (Table 2). Examples of an explicitaim were to assess the effectiveness and cultural appro-priateness of the Triple P parenting program [31]; and toevaluate the impact of a weekly subsidised box of fruitand vegetables [35]. Examples of an inferred aim were todetermine family satisfaction with a family-centred ser-vice [43, 44] and to explore the views of service pro-viders about how family-centred services work [45].

Strategies of family-centred interventionsSix key strategies were identified: supporting family behav-iours and self-care, increasing maternal knowledge, linkingwith the clinic, building the Indigenous workforce, promot-ing cultural/ community connectedness and advocating forsocial determinants of health (Table 2). Intervention com-ponents varied, with many having multiple strategies.

Supporting healthy family behaviours and self-careFourteen studies (78%) explicitly described or evaluatedthe provision of mentoring, counselling, advocacy and

Fig. 1 Flowchart of publications included in the review


Table

1Characteristicsof

stud

ies

Stud

yFirstauthor

year

Cou

ntry

setting

Participants

Aim

ofstud

yDetailsof

stud

yStud

yqu

ality

Implem

entatio

nstrategies

Outcomes

1Abe

l2015

[32]

NZ

rural

12Maorimothe

rsand10

keycommun

itystakeh

olde

rs

Und

erstandde

term

ining

factorsforthe

acceptability

ofthe

Wahakuraas

aninfant

sleeping

device

Exploratoryqu

alitative

stud

y;Interviewseither

atho

meor

work;Ethics

approval

Mod

erate

Simple,woven

flax

bassinet-like

structureto

beused

inparentalbe

d;‘safe

sleeping

rules’aimed

atredu

cing

sudd

enun

expe

cted

death

Practicalvalue(safe

bed-sharing,

easier

breast

feed

ing,

portability,

versatility,con

venien

ce);

cultu

raland

spiritual

value(naturalfib

re,sacred

andhe

alingqu

alities);

health

prom

otion(the

processof

weaving

resultedin

somewom

engiving

upsm

oking)

2App

lequ

ist

2000

[43]

USA

52NativeAmerican

femalecaregiversof

childrenwith

adisability

recruitedfro

mthreeearly

interven

tionprog

rams

Determineparental

satisfactionwith

services

Qualitativeevaluatio

n;One

time-po

intinterviews;No

ethics

approvalrepo

rted

Mod

erate

Educationaland

therapeutic

services

provided

inho

me-based,

clinicalor

centre-based

settings,p

rimarily

byparaprofession

als

Careg

iverswerege

nerally

satisfied;

moreso

with

early

interven

tion

prog

ramspe

rceivedas

morefamily-cen

tred

.Satisfactionno

tcorrelated

with

provider

norfamily

variables

3Arney

2010

[46]

AU

urban

Mothe

rs,fathe

rsand

extend

edfamily

mem

berswho

supp

orted

afamily

mem

berin

the

prog

ram

60participants

recruitedby

prog

ram

nurses

andcultu

ral

consultants

ToexploreAbo

riginal

families’p

erceptions

onthe‘Fam

ilyHom

eVisitin

gProg

ram’inAde

laideSA

Qualitativeevaluatio

n;One

time-po

intfocus

grou

psandinterviews;

Noethics

approval

repo

rted

Weak

Hom

e-basedinterven

tion

delivered

byChild

and

Family

Health

Nurses,and

CulturalC

onsultants/

Abo

riginalstaff.Intensive

stafftraining

instreng

th-

basedapproach,

attachmen

t,child

developm

ent,andsocio-

emotionalissues

Families

valued

family

inclusiveness,cultural

respect,streng

ths-based

approach,flexibilityto

addressfamily-id

entified

issues,prog

ram

convenience(hom

edelivery)andAbo

riginal

staffasabridge

with

the

mainstream

service

4Atkinson

2001

[33]

AU

urban

Represen

tatives

from

maternaland

child

health

services

intheIndige

nous

commun

ity

Tode

scrib

ethe

developm

entof

ane

wMaternaland

Child

Health

Prog

ram

runby

theTownsville

Abo

riginal

Health

Service

Qualitativeexploratory

stud

y;Sing

letim

e-po

int

forum

focussed

onqu

ality

improvem

ent,he

ldAug

ust1999;N

oethics

approvalrepo

rted

Weak

Dailymaternaland

child

health

care

plus

prim

ary

health

care

throug

hcollabo

rativeapproach

with

hospital,un

iversity,

health

service,and

Cen

trelink.

Breastfeed

ing,

nutrition

,andsm

okingcessation

prog

ram.

Child

frien

dlywaitin

groom

Increasedante-natalvisits;

decreasedpre-

term

births,low

birthweigh

t,andpe

ri-natald

eaths.

Needfor:team

approach

forIndige

nous

mothe

rsandinfants;im

proved

coordinatio

nof

services;

improved

transportand

education


Table

1Characteristicsof

stud

ies(Con

tinued)

5Ball

2005

[34]

CAN

rural

FirstNations

commun

itymem

bersfro

mthree

commun

ities

Torepo

rton

prom

ising

practices

ofintegrated

servicemod

elscentred

arou

ndearly

childho

odcare

andde

velopm

ent

prog

ramsthroug

ha

commun

ityde

velopm

ent

approach

Seriesof

grou

pforums

andindividu

alinterviews;

Noethics

approval

repo

rted

Weak

Multi-pu

rposecentre

atpu

blicscho

ol:child

care,

parent

educationand

supp

ort;servicereferral;

Nutritious

meals;

preven

tivede

ntalcare;

Prim

aryhe

alth

care

incl.

immun

isation,vision

,he

aring,andspeech

screen

ing;

Specialist

services

incl.sup

portfor

childrenwith

foetal

alcoho

lspe

ctrum

disorder;spe

echtherapy;

Culturalactivities;Social

services;C

ommun

itykitche

nandgathering

space.Training

prog

ram

inchild

andyouthcare

Servicecentrescan

becomeafocalp

oint

for

mob

ilising

commun

ityinvolvem

entin

supp

ortin

gyoun

gchildrenandfamilies;

socialcohe

sion

;acultu

ral

framearou

ndservice

usageto

inform

external

serviceprovidersand

offercultu

ralsafetyfor

commun

itymem

bers

6Barlo

w2015

[23]

USA

rural

Preg

nant

American

Indian

teen

s322participantsrecruited

from

Indian

health

service

clinics;wom

en,infants,

andchildrennu

trition

prog

rams;scho

ols,andby

wordof

mou

thInterven

tionGroup

n=159;Con

trol

Group

n=163

Toassess

theefficacyof

the‘Fam

ilySpirit’

interven

tionfor

parenting,

andfor

maternaland

child

emotionaland

behaviou

ralo

utcomes

Rand

omised

controlled

trial(RC

T)–Family

Spirit

interven

tionplus

optim

ised

care

compared

with

optim

ised

care

only;

outcom

esassessed

atbaseline(28to

32weeks

ofge

station),36weeks

ofge

station;and2,6,12,18,

24,30,and36

mon

ths

postpartum

throug

hmaternalself-rep

ort

questio

nnaires,in-person

interviews,audio

compu

ter-assisted

self-interviews,ob

servational

data,and

medicalchart

data;Ethicsapproval

Strong

43structured

pre-natal

andinfant

care

lesson

sin

“positive

parenting”

addressin

gmaternal

behaviou

rand

mental

health

prob

lems;

delivered

inparticipant’s

homes

byAmerican

Indian

paraprofessio

nalhealth

educators;Educators

received

>500htraining

Parents:

Increasedparenting

know

ledg

eandlocusof

control;fewer

depressive

symptom

s,and

externalising

prob

lems;

lower

useof

marijuana

andillegaldrug

sChildren:

Fewer

externalising,

internalising,

and

dysreg

ulationprob

lems

Barlo

w2013

[22]

Toassess

parentingand

maternaland

early

child

behaviou

ralo

utcomes

from

preg

nancyto

12mon

thspo

stpartum

Outcomes

assessed

atbaseline(32weeks’

gestation)

and2,6,

12mon

thspo

stpartum

Asabove.Increased

homesafety

attitud

es

Mullany

2012

[25]

Describes

ratio

nale,

design

,metho

ds,and

baselineresults

ofthe

Family

Spiritinterven

tion

Com

mun

ity-based

participatoryresearch

InJanu

ary2007,eligibility

criteria

–minim

umge

stationalage

was

increasedto

32weeks

Mod

erateto

high

scores

inmaternalpsycholog

icaland

behaviou

ralrisks;high

erlifetimecigarette

use

15mon

ths’pilottrial

25ho

mevisits/1

heach.


Table

1Characteristicsof

stud

ies(Con

tinued)

Walkup

2009

[26]

167participantsrecruited

from

pre-natal,and

scho

ol-based

clinics,

betw

eenMay

2002

and

May

2004.

Interven

tionGroup

n=81;C

ontrol

Group

n=86

Outcomes

assessed

atbaseline(28weeks’

gestation);2,6,and

12mon

thspo

stpartum

.Follow

upcompleted

inMay

2005.

Breastfeed

ingNutrition

prog

ram:23ho

mevisits/

1heach

Mothe

rsrepo

rted

increasedparenting

know

ledg

eDecreased

infantile

externalising

behaviou

randseparatio

ndistress

Barlo

w2006

[24]

53participantsrecruited

betw

eenJuly2001

and

Feb2002

from

four

American

Indian

health

servicecatchm

ents;

Interven

tionGroup

n=28;C

ontrol

Group

n=25

9mon

ths’pilottrial

Follow-updata

available

foron

ly19

interven

tion

and22

control

participants

Breastfeed

inged

ucation

prog

ram

only;25ho

me

visitsand41

discrete

lesson

sprovided

from

28weeks’g

estatio

nto

6mon

thspo

stpartum

Increasedparenting

know

ledg

e,skills,and

involvem

ent.

Mothe

rsin

the

interven

tiongrou

pexpe

rienced

alarger

drop

inde

pressive

symptom

s.

7Black

2013

[35]

AU

rural

167disadvantage

dAbo

riginalchildren,aged

0–17

yearswith

nutrition

riskiden

tifiedand

recruitedby

Med

ical

services

staff

Toevaluate

theim

pact

ofafru

itandvege

table

subsidyprog

ram,

delivered

byan

Abo

riginalMed

ical

Service,on

short-term

health

outcom

es

Uncon

trolledbe

fore

&afterstud

y;Outcomes

measuresassessed

after

12mon

ths;Clinical

assessmen

ts,health

record

auditsandbloo

dtesting;

Ethics

approval

Weak

Provisionof

aweeklybo

xof

subsidised

fruitand

vege

tables

linkedto

preven

tativehe

alth

services

andnu

trition

prom

otion

Fewer

visitsto

health

services,hospital

emerge

ncyde

partmen

tattend

ances,and

prescriptio

nin

oral

antib

iotics.Asm

allb

utsign

ificant

increase

inmeanhaem

oglobinlevels

butno

change

inthe

prop

ortio

nwith

iron

deficiencyandanaemia

8Blinkhorn

2012

[36]

AU

Abo

riginalHealth

workers

from

sixhe

alth

services

willrecruit72

families

with

achild

sixmon

ths

ofage

Tomon

itoralong

itudinal

oralhe

alth

education

prog

ram

toassess

the

effect

onde

ntalcaries,

feasibility,and

toinform

thede

sign

ofa

confirm

atoryrand

omised

phasethreetrial

Stud

yprotocol

-long

itudinalstudy

Repe

ated

measuresover

2yearson

parental

know

ledg

eandview

son

acceptability

ofthe

prog

ram;D

ataon

dental

carieswillbe

compared

with

data

from

ahistoricalreferencegrou

p;Ethics

approval

N/A

Abo

riginalHealth

Workers

(AHWs)willprovide

advice

ondiet,oralh

ealth

prod

ucts,child

specific

dentaladvice,edu

catio

nmaterial,andscreen

ing

forearly

childho

odcaries;

invite

mothe

rsto

ACCH

Sclinic;hom

evisitsif

appo

intm

entsmissedor

difficulties

attend

ingclinic

N/A


Table

1Characteristicsof

stud

ies(Con

tinued)

9D’Espaign

et2003

[37]

AU

remote

Abo

riginalpreg

nant

wom

en;7730ho

spital-

basedlivebirths

betw

een

1988

and2001

analysed

Toassess

theeffect

of‘Stron

gWom

en,Stron

gBabies,Stron

gCulture’

health

education

prog

ram

onbirthweigh

ts

Con

trolledbe

fore

and

afterstud

y;Group

1commen

cedprog

ram

in1993;G

roup

2in

1996

and1997;Ethicsapproval

Weak/Mod

erate

Senior

Abo

riginalwom

enprovided

advice

and

encouragem

entabou

the

althypreg

nancy

managem

entin

relatio

nto

nutrition

(includ

ing

bush

food

s),safe

practices

such

asalcoho

landsm

okingabstinen

ce,

reinforcingthene

edto

seek

adeq

uate

andtim

ely

med

icalhe

lpandto

take

prescribed

med

icines

Sign

ificant

improvem

ents

inbirth

weigh

tinGroup

1,bu

tnosig

nificantchang

einGroup

2;An

te-natalcare

aspectscouldno

tbe

assessed

dueto

incomplete

electro

nicdatacollection

10DiLallo

2014

[44]

CAN

FirstNations

preg

nant

wom

en281wom

enattend

edtheprog

ram

betw

eenNovem

ber2005

andFebruary

2009

Evaluate

theAbo

riginal

Pren

atalWellness

Prog

ram

Prog

ram

evaluatio

nPre

andpo

stsurvey

onparticipantsatisfactionNo

ethics

approvalrepo

rted

Weak

Serviceprovided

ona

continuu

mof

care

involvingcommun

ityagen

cies,health

profession

als,social

workers,life

supp

ort

coun

sellorandAbo

riginal

commun

ityElde

rs

Gen

eralhigh

satisfaction.

Improved

access

toante-natalhe

alth

care

that

iscultu

rally

sensitive,

inclusive,efficient

and

supp

ortive.Increase

inreturningclientele.

Increasedbreastfeed

ing.

Decreased

maternal

smokinganddrinking

11Edmun

ds,

2016

AUS

remote

170Abo

riginalpreg

nant

wom

enandmothe

rsandbabies

to6mon

ths

post-partum

from

Cape

York

commun

ities,

Abo

riginalHealth

Workers

Evaluate

theim

pact

oftheBaby

Basket

prog

ram

asim

plem

entedin

Cape

York

byApu

nipimaCape

York

Health

Cou

ncil,and

aspe

ctsof

theprog

ram

that

aretransferableto

othe

rregion

sandothe

rgrou

ps

Mixed

metho

dstud

y:qu

alitativegrou

nded

theo

rymetho

dsbasedon

interviewsandfocus

grou

pswith

wom

enwho

received

Baby

Baskets,

family

mem

bers,and

healthcare

workers.

Quantitativecomparative

analysisof

routine

indicatorsof

Apu

nipima

commun

ities

andne

arby

GulfandTorres;and

Baby

Basket

surveys.Cost

analysisto

estim

atethe

resourcesrequ

iredto

deliver

theBaby

Basket

Costin

g:Mod

erate

Qualitative:Mod

erate

Quantitative:Weak

Encourages

early

and

frequ

entattend

ance

atantenatalclinicsand

regu

larpo

stnatal

check-

ups.Engage

men

tisfacilitated

byde

liveryof

threeBaby

Baskets

includ

ingfivefood

vouche

rsto

wom

en.

Basketsarede

livered

inthefirsttrim

ester,

immed

iatelypriorto

birth

andpo

stbirth.Education

abou

the

althychoices

arou

ndsm

oking,

alcoho

landdiet.

Thecore

concernof

implem

entatio

nwas

term

edworking

towards

anem

poweringfamily-

centredapproach.

Com

paredwith

the

controlsites:Apu

nipima

siteshadahigh

erprop

ortio

nof

early

and

morefre

quen

tantenatal

visits,low

erlevelsof

iron

deficiencyin

preg

nant

wom

en,d

eclininglevels

offalterin

ggrow

thin

children.Bu

talso

increasing

smokingin

preg

nant

wom

enand

inconsistent

results

abou

ted

ucation.Costpe

rparticipantwas

mod

est

($874).

McCalman,

2015

[29]

McCalman,

2014

[28]


Table

1Characteristicsof

stud

ies(Con

tinued)

11Elliott

2012

[38]

AU

remote

Abo

riginalparentsand

carersof

allchildrenbo

rnin

theFitzroyValley

region

,Western

Australia

betw

een2002

and2003

Describestrategy

developm

entforthe

diagno

sisandpreven

tion

ofFoetalAlcoh

olSpectrum

Disorde

rs(FASD

);andthesupp

ort

forparentsandcarersof

affected

childrenthroug

hindividu

altreatm

entplans

Descriptivestud

yInform

ationabou

tantenatalexposures;early

lifetrauma;andhe

alth

andde

velopm

entof

parentsandcarerswas

obtained

viaamed

ical

checklist;Ethics

approval

N/A

Abo

riginalorganisatio

nspartne

redwith

researchersto

successfully

lobb

yforrestrictedaccess

toalcoho

l;cond

ucteda

FASD

prevalen

cestud

yfollowingextensive

commun

ityconsultatio

nandconsen

t.Prog

ram

includ

escommun

ityed

ucation;supp

ortfor

parentsandcarers;advice

forteache

rs

Datawillbe

used

bythe

commun

ityto

advocate

forim

proved

services

and

new

mod

elsof

health

care

12Harvey-

Berin

o2003

[39]

USA

43mothersandtheir

preschoo

lNative-American

children

Tode

term

inewhe

ther

maternalp

articipationin

anob

esity

preven

tion

plus

parentingsupp

ort

prog

ram

was

feasibleand

effectivein

redu

cing

the

prevalen

ceof

childho

odob

esity

RCTcomparin

gob

esity

preven

tion&parenting

supp

ortwith

parenting

supp

ortalon

e;40

participantsassessed

;20

each

intreatm

entand

controlg

roup

s;Recruitm

entviamed

iaadvertisem

ents,d

aycare

centres,nu

trition

prog

ram,self-referral,

inform

alne

tworking

incommun

ity;O

utcome

measuresassessed

atbaselineand16

weeks;

Ethics

approval

Mod

erate

11parentinglesson

scond

uctedover

16weeks

intheparent’sho

me;

training

provided

forpe

ered

ucator

andproject

director

Decreased

weigh

tgain

inchildrenin

theob

esity

preven

tion&parenting

supp

ortgrou

p.Inconclusive

data

onwhe

ther

parentspo

sing

restrictio

nson

feed

ing

influen

cedweigh

tgain

13Hom

er2012

[40]

AU

urban

353Abo

riginalandTorres

StraitIsland

erpreg

nant

wom

enwho

attend

edtheMalabar

serviceand

gave

birthdu

ring2007

and2008

Toevaluate

whe

ther

and

towhatextent

the

Malabar

Com

mun

ityMidwifery

Link

Service

was

meetin

gthene

eds

ofwom

enclientsand

staff

Before

andafterstud

y;Repe

ated

measuresof

clinicaldata

anddata

onsm

oking/alcoho

luse;

Focus-grou

pdata

aton

etim

e-po

intof

wom

ens’

satisfactionwith

the

service;Ethics

approval

Mod

erate(qualitative

compo

nent);Weak

(quantitativecompo

nent)

Midwifery

continuity

ofcare

durin

gpreg

nancy,

labo

urandbirth;and

post-natallywith

referral

tochild

health

services

afterdischarge;serviceis

either

hospitalo

rho

me

based;

transportprovided

forbe

tter

access

Wom

enfelttheservice

provided

ease

ofaccess,

continuity

ofcare

and

carer,trustandtrustin

grelatio

nships.Earlyaccess

topreg

nancycare.

Redu

cedsm

okingdu

ring

preg

nancy.Health

prom

otionprog

rams

develope

dthat

target

smokingandalcoho

lconsum

ptiondu

ring

preg

nancy


Table

1Characteristicsof

stud

ies(Con

tinued)

14Mun

ns2010

[41]

AU

remote

Parents,carers,and

ante-natalclientsof

childrenaged

0–3years

livingin

thetownof

Halls

Creek,W

estern

Australia

Tode

scrib

ethe

introd

uctio

nof

anIndige

nous

homevisitin

gparent

supp

ortprog

ram

toen

hanceprom

otionof

behaviou

raland

attitud

inalchange

sto

parenting

Casestud

y/prog

ram

descrip

tion;Agrou

pof

strong

men

andwom

enas

homevisitors;w

orking

inconjun

ctionwith

commun

itychild

health

nurses

andmidwives;N

oethics

approvalrepo

rted

N/A

Enhanced

prom

otionof

behaviou

raland

attitud

inalchange

sto

parenting;

mon

thly1h

homevisitsby

Indige

nous

peer

supp

ort

team

(exten

dedandin

othe

rlocatio

nsif

need

ed);may

betw

oor

threeho

mevisitorsto

accommod

atedifferent

lang

uage

s,family,and

cultu

ralissues;he

alth

prom

otionthroug

hpictorialh

ando

uts;

Inclusionof

cultu

reand

lore.Train

thetraine

rprog

ram

Not

repo

rted

15Po

ole

2000

[42]

CAN

urban

18preg

nant

Abo

riginal

wom

enwith

substance

useprob

lemswho

accessed

theservicein

1988;trackingof

12clientswho

accessed

services

July1999

and

Decem

ber1999;surveys

completed

by10

staff

andthreeCou

ncil

mem

bers;survey

completed

by21

key

inform

ants

Evaluatio

nof

theShew

ayProg

ram

Qualitativeprog

ram

evaluatio

n;Artexpression

combine

dwith

afocus

grou

pto

capture

wom

en’spe

rspe

ctives

ontheservice.Filereview

ofbirthandhe

alth

outcom

es.

Datacomparedwith

inform

ationon

wom

enclientsfro

mtw

oprevious

years.Noethics

approval

repo

rted

Mod

erate

Dailyho

tnu

tritiou

slunche

s,food

coup

ons,

food

bank

hampe

rsand

nutrition

alsupp

lemen

ts,

busfare

for

appo

intm

ents,formula,

napp

ies,clothing

,eq

uipm

entandothe

ritemsforne

wbo

rninfants,ou

treach

and

homevisits,recreational

andcreativeprog

rams,

nutrition

coun

selling

and

supp

ort,alcoho

land

drug

coun

selling

,methado

neprescribing,

supp

ortin

developing

/im

proving

parentingskills,advocacy

onho

usingandlegal

issues

Improved

nutrition

alou

tcom

es,d

ecreased

substancemisuse,

improvem

entin

housing,

lower

ratesof

child

appreh

ension

bythe

Ministryof

Childrenand

Family

developm

ent,

healthierbirthweigh

ts,

up-todate

immun

isations


Table

1Characteristicsof

stud

ies(Con

tinued)

16Thom

as2015

[45]

AU

12servicemanagers,

paed

iatricregistrars,early

childho

odhe

alth

nurse,

midwife,A

borig

inal

health

educationofficer,

speech

patholog

ist,

manager

ofparenting

supp

ortprog

ram

Toexploretheview

sof

serviceproviderson

how

paed

iatricou

treach

services

workin

partne

rshipwith

othe

rservices,A

borig

inal

families

andthe

commun

ity,and

how

thosepartne

rships

could

beim

proved

Qualitativeon

e-po

intin

timestud

y;In-depth

semi-structured

interviews,

focusgrou

ps;Ethics

approval

Mod

erate

Form

alandinform

alapproaches

tofacilitate

relatio

nships

betw

een

serviceprovidersand

families,ensuringchildren

receivequ

ality

care

whe

nandwhe

rethey

need

it.Partne

rships

foun

dedon

acultu

rally

approp

riate

mod

elof

care

that

was

non-judg

emen

tal,based

ontrustandrespect,and

recogn

ised

holistic

health

andwellness

Moretim

efor

consultatio

nsandmore

oppo

rtun

ityforfollow-up

than

wou

ldno

rmally

occurin

theou

tpatient

setting;

leadership

was

essentialcom

pone

ntof

effectivepartne

rships

17Turner

2007a[30]

AU

urban

51Indige

nous

families;

n=26

treatm

entgrou

p,n=25

controlg

roup

(waitlistfor8weeks)

Toassess

the

effectiven

essandcultu

ral

approp

riatene

ssof

the

TriplePparenting

prog

ram

Rand

omised

grou

pde

sign

with

repe

ated

measures;ou

tcom

emeasuresassessed

at6mon

ths;recruitm

ent

throug

hho

me-based

interview;noethics

approvalrepo

rted

Mod

erate

Eigh

t-sessionprog

ram,

usingactiveskillstraining

processto

help

parents

acqu

irene

wknow

ledg

eandskills.

Highconsum

ersatisfaction;breakdo

wn

ofob

staclesin

accessing

mainstream

services;

sign

ificant

decreasesin

prob

lem

child

behaviou

r;sign

ificant

decrease

inrelianceon

dysfun

ctional

parentingpractices

Turner

2007b[31]

Non

-Indige

nous

researchers

Toreflect

onacultu

rally

sensitive

adaptatio

nof

amainstream

interven

tion,

the“Trip

lePParenting

Prog

ram”

Reflectivepape

rNoethics

approvalrepo

rted

N/A

App

ointingprojectstaff

canbe

complex

and

sensitive.N

eed

commun

ityacceptance

andsupp

ort;sensitivity

toparticipant’s

issues;

flexibleaccess

toservices;

strategies

toovercome

literacyandlang

uage

barriers;awaren

essthat

complex

family

issues

may

impact

grou

pdynamics;sharingof

outcom

eswith

commun

ity


products to support healthy family behaviours and self-care [28–34, 41–44, 46]. Mentoring by IndigenousElders and/or health professionals was provided toencourage reduced or no alcohol use and smoking in preg-nancy [28, 29, 37, 38, 42, 43]; improve nutrition in preg-nancy [28, 29, 35, 37, 42, 44]; safe sleeping [28, 29, 32];early childhood healthy eating and exercise routines toreduce obesity [28, 29, 39]; and care for and learning bydisabled children [40]. As well, parents/caregivers werementored to care for themselves [43] and reward them-selves for meeting goals [36]. Counselling or brief interven-tions were provided to enhance nutrition and reducealcohol and drug use [28, 29, 42]. Advocacy was also re-ported, for example to assist with housing, welfare andlegal issues [28, 29, 42] and for improved services and newmodels of healthcare [38].Products, such as food and nutritional supplements,

were provided to support women during pregnancy. Forexample, the Australian Baby Basket program providedantenatal, perinatal and postnatal baskets to Cape Yorkwomen, which included a baby bed, educational booksand clothing, nappies and other items for the baby andmother [29]. The Canadian Sheway program provideddaily hot nutritious lunches, food coupons, food bankhampers and nutritional supplements for pregnantwomen struggling with substance abuse and addictions[42]. Products were also provided for new born infants,such as formula, nappies, clothing, and equipment suchas sleeping baskets. Examples included the New ZealandWahakura, a flax bassinet which was provided to pro-mote safe sleeping for Maori infants [29], the CanadianSheway program’s provision of items for newborn infants[42], and an Australian Aboriginal Medical Service’sprovision of a weekly box of subsidised fruit and vegeta-bles linked to preventative health services and nutritionpromotion [35].

Increasing maternal knowledge and skillsAll 18 studies (100%) explicitly evaluated or describedmaternal health education and skills development. The

foci of these strategies was to promote maternal skillsgenerally, e.g. [22–26, 28–30], problem solving and cop-ing skills [26, 31], goal setting [24, 46], breast feedingand nutrition skills [28, 29, 39], dental health knowledge[36], safe sleeping [28, 29], smoking and alcohol reduction[28, 29] and the promotion of children’s competence anddevelopment and management of misbehaviour [31].Group or individual parent education was delivered in for-mal training or in home settings. To overcome literacyand language barriers, training was provided in intensivesmall group sessions or individually [26, 30, 31], andresources were made available in simple English, audiovisually, and as table top flip charts [26, 28, 29, 31].

Linking with the clinicEight studies (44%) explicitly reported linking familieswith clinical services [27, 28, 30, 31, 34, 37, 41, 42]. Insome interventions, program educators encouraged fam-ily members to attend the health clinic for antenatalchecks and birthing [28, 29, 33, 40, 44], to seek timelymedical help [31, 37], for immunization [28, 29, 34, 40],screening for vision, hearing and speech [34], and spe-cialist paediatric services [34, 45].

Building the Indigenous workforceFourteen studies (78%) reported employment, trainingand supervision of an Indigenous workforce as a strategy[22–26, 28, 29, 33–46]. For example, two newly gradu-ated Aboriginal midwives were mentored through anurban Australian community midwifery service [40].The Native American educators of the Family Spirit

intervention were required to complete 500 h of trainingin home-visiting methods and curricular content, had todemonstrate competency in the form of written and oralexaminations, and received daily on-site supervision andweekly cross-site conference calls [22–26]. Similarly, anAustralian nurse home-visiting intervention providedextensive training for Aboriginal staff instrength-basedapproaches to attachment theory, child development andsocio-emotional issues facing families [28, 29, 46].

Fig. 2 Number of each type of study design


Table

2Interven

tionaims,strategies,enablersando

utcomes

Aim

Strategies

Enablingcond

ition

s

Firstauthor

year

Prom

ote

healthy

families

Supp

ortin

gfamily

behaviou

rs&

self-care

Increasing

maternal

know

ledg

eandskills

Linking

with

the

clinic

Buildingthe

Indige

nous

workforce

Prom

oting

cultu

ral/

commun

ityconn

ectedn

ess

Advocating

forsocial

determ

inants

ofhe

alth

Com

petent

and

compassionate

staff

Flexibility

ofaccess

Con

tinuity

&integration

ofcare

Culturally

supp

ortive

care

Abe

l,2015

[33]

✓✓

✓X

~✓

XX

✓X

✓

App

lequ

ist,2000

[44]

~✓

✓~

✓X

X✓

✓✓

✓

Arney,2010[47]

~✓

✓~

✓X

~✓

✓✓

✓

Atkinson,2001

[34]

✓X

✓✓

✓X

X~

✓✓

✓

Ball,2005

[35]

✓✓

✓✓

✓✓

✓~

✓✓

✓

Barlo

w,2015[24],2013[23],2006[25];

Mullany

2012

[26],W

alkup,

2009

[27]

✓~

✓~

✓X

X✓

✓✓

✓

Black,2013

[36]

✓✓

✓~

XX

X~

✓✓

~

Blinkhorn,2012

[37]

✓✓

✓~

✓X

XX

✓✓

✓

D’Espaign

et,2003[38]

✓✓

✓✓

✓✓

X✓

✓X

✓

DiLallo,2014[45]

~✓

✓✓

✓X

~✓

✓✓

✓

Elliott,2012[39]

✓✓

✓~

✓✓

✓X

✓X

✓

Harvey-Berin

o,2003

[40]

✓✓

✓~

✓X

XX

✓X

~

Hom

er,2012[41]

✓X

✓✓

✓X

X✓

✓✓

✓

McCalman,2014[29],2015[30];Edm

unds

2016

[54]

✓✓

✓✓

✓X

X✓

✓~

✓

Mun

ns,2010[42]

✓✓

✓~

✓X

X✓

✓✓

✓

Poole,2000

[43]

✓✓

✓~

✓✓

✓✓

✓✓

✓

Thom

as,2015[46]

~X

✓✓

XX

X✓

✓✓

✓

Turner,2007a

[31];2007b

[32]

✓✓

✓✓

~X

X✓

✓X

✓


Table

2Interven

tionaims,strategies,enablersando

utcomes

(Con

tinued)

Aim

Outcomes

Firstauthor

year

Prom

ote

healthy

families

Child

nutrition

alstatus

Child

emotional

behaviou

r

Child

preven

tive

health

incl.safety

Parental

depression

,substanceuse

Parentingknow

ledg

e,confiden

ceandskills

Health

service

satisfaction

Health

service

utilisatio

n/access

and

cost

Com

mun

ity/

cultu

ral

reviatlisation

Abe

l,2015

[33]

✓X

X✓

✓✓

✓X

✓

App

lequ

ist,2000

[44]

~X

✓X

X✓

✓X

X

Arney,2010[47]

~X

X~

~✓

✓X

X

Atkinson,2001

[34]

✓✓

XX

X~

✓✓

X

Ball,2005

[35]

✓~

✓✓

~✓

✓X

✓

Barlo

w,2015[24],2013[23],2006[25];

Mullany

2012

[26],W

alkup,

2009

[27]

✓X

✓✓

✓✓

XX

✓

Black,2013

[36]

✓✓

X✓

X~

X✓

✓

Blinkhorn,2012

[37]

✓X

XX

XX

XX

X

D’Espaign

et,2003[38]

✓✓

XX

X~

XX

✓

DiLallo,2014[45]

~✓

XX

✓~

✓✓

X

Elliott,2012[39]

✓X

XX

XX

XX

~

Harvey-Berin

o,2003

[40]

✓✓

XX

X✓

XX

X

Hom

er,2012[41]

✓X

XX

✓~

✓✓

X

McCalman,2014[29],2015[30];Edm

unds

2016

[54]

✓✓

XX

✓✓

✓✓

X

Mun

ns,2010[42]

✓X

XX

XX

~X

X

Poole,2000

[43]

✓✓

X✓

✓~

✓X

X

Thom

as,2015[46]

~X

XX

XX

~✓

X

Turner,2007a

[31];2007b

[32]

✓X

✓X

X✓

✓✓

X


Promoting cultural/Community connectednessFive studies (28%) explicitly promoted cultural, spiritual orcommunity connectedness as a strategy [32, 34, 37, 41, 42].For example, new Maori parents were encouraged to use asafe sleeping device made from native flax, a materialwhich had traditionally been used for weaving and wasconsidered to have sacred and healing qualities [32].Aboriginal Australian pregnant women were encouragedto make greater use of bush foods [37] and to becomemore engaged with local community events [41]. Canadianstudies described early childhood care and developmentprograms as a ‘hub’ for meeting a range of service andsocial support needs of community members [34] andencouraged pregnant women to identify a network ofpeople whom they could call upon for support [42].

Advocating for social determinants of healthThree studies (17%) described advocacy to improve as-pects of the social and/or economic determinants ofhealth [34, 38, 42]. Studies considered family-centred careto be a ‘hook’ for mobilising community involvement insupporting young children and families [34], advocated torestrict the sale of full-strength alcohol [38], and providedadvocacy and support for child access and custody, otherlegal issues and housing [42].

Enablers of family-centred interventionsThe four enablers of family-centred interventions werecompetent and compassionate program deliverers, flexi-bility of access, continuity and integration of care, andculturally supportive care (Table 2).

Competent and compassionate program deliverersEleven studies (61%) cited the importance of having com-petent and compassionate staff as an enabler of family-centred care [22–26, 28–31, 37, 40–44, 46]. For example,Arney et al. [46] found that families’ views about the pro-gram could not be separated from their appreciation ofthe qualities and abilities of the staff. Barlow et al. [22–24]required staff to have the ability to show compassion, benon-judgmental and have inter-personal skills.Other publications emphasised the need for cultural

sensitivity training to promote the interaction of practi-tioners with clients in ways that respected their culturalorientations and living situations [26, 30, 31]. Sevenpublications referred to the cultural competence ofIndigenous program deliverers who could accommo-date different languages, family and cultural issues[22–24, 28, 29, 37, 41, 42]. Homer et al. [40] however,found that it was the trusting relationship betweenprovider and client that was important; this was not ne-cessarily with an Aboriginal provider. Applequist & Bailey[43] found that 96% clients indicated no preference re-garding the ethnic background of their service provider.

Flexibility of accessAnother hallmark of family-centred care interventionswas the flexibility of access provided to health educationand care. All 18 of the included studies (100%) reportedflexibility of access, including the provision of home-based care, e.g. [22–26, 28, 29, 31], choice of traininglocation, e.g. [30, 31], or less commonly, the provision oftransport or transport vouchers to and from services[40, 42]. Service providers considered it important toprovide flexible access as an enabler of engagement, par-ticularly to families without means of transport.

Continuity and integration of healthcareAnother enabler, reported in 12/18 studies (67%), wasthe provision of healthcare continuity and integration bylinking women across antenatal, birthing and postnatalservices and providing integrated wrap-around care[22–26, 33–36, 40–46]. For example, Homer et al. [40]described a healthcare model whereby women wereoffered continuity of midwifery care during pregnancy,labour and birth; and referral to child health services post-natally after discharge.Community agencies, health professionals, social wor-

kers, life support counsellors, and community Elderscollaborated to provide integrated, wrap-around care forfamilies [41, 44, 46]. Intercultural collaboration acrossIndigenous and mainstream health services was alsoconsidered important [44–46]. Leadership was consid-ered an essential component of effective partnershipswith other services, families and the community as it en-hanced workplace ethos and created an environmentwhere collaboration was supported [45].

Culturally supportive careCulturally supportive care, based on secure, respectfuland reciprocal relationships and partnerships with expli-cit respect for diversity, was highlighted in 16/18 studies(89%) [22–26, 28–38, 40–46]. Being community driven,e.g. [38] or incorporating culture and lore, e.g. [41] wasseen to enhance the effectiveness of programs and breakdown obstacles to accessing mainstream services, e.g.[31]. In some interventions, clients were provided achoice of the participants’ native language or English forhealth education delivery [22–26, 41].

OutcomesIntervention outcomes were reported in the 15/18 evalu-ation studies (83%) [22–26, 28, 29, 31–34, 37, 39, 40, 42–46]for Indigenous children, parents/caregivers, health ser-vices, and broader community/culture (Table 2). ForIndigenous children, reported outcomes included im-proved nutritional status, emotional and behavioural andpreventive health. For parents/caregivers of Indigenouschildren, studies reported reduced parental/caregiver


depression and substance abuse, and improved parenting/caregiving knowledge, confidence and skills. For healthservices, reported outcomes included client satisfactionand improved service utilisation and cost of delivery.Community/cultural revitalisation was also reported. Twostudies that described programs [38, 41] and one studyprotocol [36] did not report outcomes.

Child health outcomesChildren’s nutritional statusSeven/15 studies (47%) reported improvements inchildren’s nutritional status including changes inweight (overweight and underweight), growth and/ornutritional markers such as increased haemoglobinlevels [28, 29, 33, 35, 37, 39, 42, 44]. Improved birthweights were reported following advice in relation to nu-trition, alcohol and smoking during pregnancy, and util-isation of adequate and timely medical help [33, 37, 42].Increased breast feeding was reported in a self-report sur-vey following an Aboriginal Prenatal Wellness Program[44]. A reduced incidence of faltering growth was reportedin an evaluation of the Australian Baby Basket program[28] and a small but significant increase in mean haemo-globin levels of children was found in a similar Australianstudy following the provision of a weekly box of subsidisedfruit and vegetables linked to preventative health servicesand nutrition promotion [35]. Finally, decreased weightgain in children in the obesity prevention group of a USrandomised controlled trial was found following an obes-ity prevention intervention with mothers of preschoolNative-American children [39].

Children’s emotional behaviourFour/15 studies (27%) reported improvements in chil-dren’s emotional behavior [22–26, 31, 34, 43]. Improvedcoping strategies, self-expression and compliance werereported, as were lower rates of infant separation distressand child anxiety [22, 23, 26, 31, 42]. Fewer behaviouralproblems such as physical aggression, disobeying rules,fearfulness, separation distress, social withdrawal, orpoorly modulated emotional responses in children werealso found in the US ‘Family Spirit’ [22, 23, 26] andAustralian Triple P [31] interventions.

Preventing childhood injury and illnessFive/15 studies (33%) reported outcomes related to the pre-vention of childhood injury and illness [22–26, 32, 34, 35].Improvements were found in attitudes toward, or actualhome safety [22, 23, 32, 35]. For example, the US FamilySpirit intervention resulted in an increased awareness ofhome safety issues in teen mothers [22, 23, 26]. The NewZealand Wahakura, a woven flax bassinet delivered withsafe sleep messages, improved parental reassurance andconfidence while providing the infant with a safe place to

sleep in the parental bed [32]. The Canadian Sheway pro-gram resulted in housing improvement and lower rates ofchild apprehension by the Ministry of Children and Familydevelopment [42]. Studies also reported up to date immu-nisations [34, 42], screening for children’s vision, hearing,and speech [34], and a significant decrease in prescribedoral antibiotics [35].

Parent/carer outcomesParent/Carer’s depression and substance misuseSix/15 studies (40%) reported reductions in parental/carer depression and/or substance misuse [22–24, 26,28, 29, 32, 40, 42, 44]. For example, American Indian teenmothers had fewer externalising problems and depressivesymptoms after participation in the Family Spirit interven-tion [22, 23]. Similarly, Poole [42] reported decreased sub-stance misuse by pregnant women who participated in theCanadian Sheway program. Also reported were reductionsin maternal smoking [32, 40, 42, 44] and use of marijuanaand other illegal drugs [23, 42]. The Australian BabyBasket program was associated with a decrease in womenwho consumed alcohol during pregnancy over time. Allwomen who consumed alcohol during pregnancy in 2013were provided a brief intervention [28].

Parenting/Caregiving knowledge, confidence and skillsEight/15 studies (53%) reported improvements inparenting/caregiving knowledge, confidence and skills[22–24, 26, 28, 29, 31, 32, 39, 43, 46]. For example, im-proved parenting knowledge and locus of control werefound in Native American teen mothers following theUS Family Spirit intervention [22–24, 26]. Similarly, anAustralian nurse- delivered home visiting program re-sulted in an improved sense of confidence in parenting[46]. Turner et al. [31] and Munns [41] found behaviouraland attitudinal changes to parenting including a signifi-cant decrease in reliance on some dysfunctional parentingskills. The other five publications that explicitly aimed toenhance parental skills and practices were protocols orprogram descriptions and did not report outcomes.

Health service outcomesSatisfaction with healthcareTen/15 studies (67%) reported high satisfaction withfamily-centred health service provision [28, 29, 31–35, 40,42–44, 46] with greater satisfaction reported for programsthat were perceived to be more family-centred [43].

Healthcare access, utilisation and costSeven/15 studies (47%) reported improved health ac-cess or utilisation as an outcome of family-centredcare [24, 27–29, 31, 33, 35, 40, 44, 45]. Culturally ap-propriate services were seen to promote more time forconsultations and more opportunity for follow-up than


would normally occur in an outpatient setting [28, 44, 45].Also reported were earlier and increased utilisation ofante-natal care services [28, 33, 40] and a breakdown ofsome of the obstacles Indigenous families faced in acces-sing mainstream services [31]. A reduction in visits tohealth services for illness, hospital emergency departmentattendances and oral antibiotic prescriptions was alsofound [35]. The Australian Baby Basket program evalu-ation reported that the cost per Baby Basket participant ofabout $874 appeared to be a modest investment to pro-vide babies with a better start in life [27].

Community/cultural revitalizationFinally, five/15 studies (33%) reported community orcultural revitalisation as a result of implementing afamily-centred intervention [22–24, 26, 32, 34, 35, 37].The cultural and spiritual value of interventions wasconsidered to be an outcome in its own right; for ex-ample, the Wahakura woven flax bassinet had culturaland spiritual value as well as promoting safe sleepingpractices [32]. Centre-based interventions also became afocal hub for mobilising community involvement insupporting young children and families and encouragingsocial cohesion [34], as well as a basis to advocate forimproved models of healthcare that offered culturalsafety for community members [34, 38]. The employ-ment of Indigenous para-professionals was also consid-ered to have the potential to break multigenerationalcycles of behavioural health disparities for Indigenouscommunities [22, 23, 26, 35, 37].

LimitationsAlthough a rigorous and thorough search strategy wasused, it is possible that this scoping review did not locateall relevant studies. There was high level of agreementbetween blinded coders, and consensus on all includedstudies, but it is also possible that relevant interventiondescriptions or evaluations may have been misclassified.Since evaluations with statistically significant findingsare more likely to be published, it is possible that thepublished evaluations reviewed overestimate the true ef-fectiveness of family-centred interventions in health carefor Indigenous peoples [47].

DiscussionThis review considered the current evidence base for theimpact of family-centred interventions on Indigenousearly childhood health. Like other reviews of Indigenoushealth [48, 49], we found little impact evaluation re-search that aimed to test the effectiveness of interven-tions, and only one study was rated of strong quality.The preponderance of the literature about family-centred interventions focussed on program descriptionsor qualitative process evaluations, which explore the

concepts and issues and described the interventions andformative or intermediate outcomes. It is likely that thisis because the field is still in the relatively early stages ofdevelopment, therefore there has not been enoughelapsed time for follow-up studies and thus we do notknow the full impact on Indigenous families of family-centred interventions.The best evidence available suggest family-centred in-

terventions can not only improve Indigenous children’shealth but also the health of their parents/caregivers.Studies suggest that outcomes include improved birthweights [33, 37, 42] and reduced weight gain of obesechildren [39], reduced children’s problem behaviours[22, 23, 26, 31], improved home safety, e.g. [23, 32, 42], andimproved immunisation and screening rates [34, 35, 42].Interventions also increased parenting knowledge

[22, 24, 26, 31], involvement [24], locus of control [23],self-efficacy [22] and decreased reliance on some dys-functional parenting practices [31]. Through improvingparenting knowledge and skills, the interventions mayhave reduced the physical aggression of parents/caregivers[22, 23], depressive symptoms and past month use ofmarijuana and illegal drugs [23]. Health services experi-enced high rates of consumer satisfaction [31, 43], and im-proved access to mainstream services [31]. No adverseeffects were reported. No study directly addressed theultimate outcome of decreased morbidity as a result of theintervention.A key gap in the evidence related to family engage-

ment with and positioning in interventions. Family-centred care is based on the principle that parents bringexpertise at both the individual care-giving level and thesystems level [50]. However, few studies reported the ex-tent to which families engaged in the family-centred in-terventions. Instead studies described the interventioncomponents of a family-centred approach, focussed ontheir acceptability or feasibility, or users’ satisfaction withservices, or evaluated their health outcomes and/orcosts. Thus MacKean’s ([50] p. 81) observation of main-stream healthcare settings where; “family-centred care isbeginning to sound like something that is being definedby experts and then carried out to families, which isironic given that the concept of family-centred careemerged from a strong family advocacy movement” mayalso be apt in Indigenous settings. This finding may berelated to use of a definition of family-centredcare devel-oped for health service (rather than broader community)settings. However, the finding suggests that there is animportant opportunity to develop a model of Indigenousfamily-centred care in the wider community context.We found only three studies which considered the value

of family-centred approaches in responding to the up-stream social and economic determinants of Indigenouspeople's relatively poor health. The paucity of evidence in


this area is of concern given the tendency identified byPopay et al. [51] for policies and programs to lifestyle drift;that is, to recognise the importance of the structural/political determinants of health inequalities but to re-spond with action largely on behavioural lifestyle foci.Another key gap identified in the reporting of inter-

vention strategies pertained to the role of fathers infamily-centred care. Ball [52] cited mother-centrism inparenting practices and child welfare services as barriersto positive involvement of Indigenous fathers with theirchildren’s health and wellbeing, yet none of the includedstudies explicitly considered the role of fathers. Furtherevaluation of the role of fathers in family-centred careinterventions is needed through effective partnershipsbetween primary healthcare services and research agen-cies to evaluate family-centred interventions as they rollout, thus minimising evaluation costs and optimising theuse of locally available resources.Only one study provided evidence of the costs of pro-

viding family-centred care to Indigenous families [27],and suggested that costs were offset by potential bene-fits. The paucity of economic evaluations was an identi-fied gap in the scoping review. Another study of anintervention where senior Aboriginal women providedcultural support to pregnant women from remote Aus-tralian communities during labour, which was excludedfrom the review because it did not continue past onemonth post-partum, also found that the interventionwas likely to be cost effective [53]. The finding suggeststhe potential for such interventions to be cost effective,but further such evaluations are needed.A crucial issue in translating the results of this scoping

review into policy or practice to inform interventions forimproved Indigenous family health is that while thescoping study mapped the research and found 18 stud-ies, these were generally of moderate to weak quality.This scoping review was conducted to produce a broadmap of the evidence and to inform the scope and re-search objective of a Cochrane review protocol [3]. TheCochrane review will provide an independent and rigor-ous investigation, updated regularly to incorporate newresearch, of the best available evidence for the effects offamily-centred interventions for children and theirfamilies. The Cochrane review will ensure that primaryhealthcare services can base their decisions aboutoptimal interventions for the improvement of families’health on current and reliable evidence.

ConclusionFamily-centred interventions produced outcomes of im-proving Indigenous early childhood wellbeing, and thehealth of parents/ caregivers, as well as consumer satis-faction and improved access to mainstream services.The 18 studies evaluated or described the required

conditions for implementing family-centred care to bethe availability of competent and compassionate pro-gram deliverers, flexibility of access, continuity and inte-gration of healthcare and culturally supportive care.Strategies were diverse and included supporting familybehaviours and self-care, increasing maternal knowledge,strengthening links with the clinic, building the Indigen-ous workforce, promoting cultural or community con-nectedness and advocating for the social determinants ofhealth. However, the evidence base for family-centred in-terventions by primary healthcare services is in an earlystage of development, with few impact evaluation studiesavailable. As well, there was little explanation in theavailable studies of how families engaged with and werepositioned within family-centred interventions, whetheror how interventions were able to impact the social de-terminants of families’ health, the role of fathers infamily-centred care and the costs of providing family-centred care. This scoping review informs the develop-ment of a Cochrane review protocol, which will provideregular updates of the available evidence as it develops.

AbbreviationsISAC: Centre for Research Excellence for Improving Health Services forAboriginal and Torres Strait Islander Children; PRISMA: Preferred ReportingItems for Systematic Reviews and Meta-Analyses

AcknowledgementsChief investigators and Apunipima staff members, Drs Mark Wenitong andAlan Ruben, approved the grant and the Apunipima Research GovernanceCommittee approved the publication. Thanks to Katrina Keith whoconducted the search of the electronic databases and websites, and theApunipima, ISAC and associated colleagues who conducted the blindedscreening of the publications. They were Karen Edmond, Rhonda Marriott,Michelle Redman-MacLaren, Linda Shields, Komla Tsey and Mark Wenitong.Thanks to Irina Kinchin who assessed the quality of the costing study. Thanksalso to Karla Canuto, Research Co-ordinator at Apunipima Cape York HealthCouncil, who provided critical feedback on the final draft of this paper.

FundingThis research was funded by a grant from the National Health and MedicalResearch Council Centre for Research Excellence Improving Health Servicesfor Aboriginal and Torres Strait Islander Children (ISAC) via Apunipima CapeYork Health Council. The funding body played no role in the design of thestudy and collection, analysis, and interpretation of data or writing themanuscript.

Availability of data and materialsThe data supporting our findings is provided in Table 1. A database of thesearch strategy records is available on request from the correspondingauthor.

Authors’ contributionsJM led the scoping review, assessed the quality of qualitative studies anddrafted the manuscript. MH developed Table 1, assessed the quality ofqualitative studies, coded the data and contributed to drafting themanuscript. SC and CC assessed the quality of quantitative studies. RB, NSand AR made substantial contributions to conception and design of thereview. All authors screened the publications, revised the manuscriptcritically for intellectual content, and read and approved the final manuscript.

Authors’ informationSC, RB and CC are Aboriginal Australian researchers. JM, MH, NS and AR arenon-Indigenous.


Competing interestsThe authors declare that they have no competing interests.

Consent for publicationNot applicable.

Ethics approval and consent to participateNot applicable.

Author details1Central Queensland University, Cairns, Australia. 2James Cook University,Cairns, Australia. 3University of Melbourne, Melbourne, Australia. 4Universityof Western Australia, Crawley, Australia. 5Apunipima Cape York HealthCouncil, Bungalow, Australia.

Received: 28 October 2016 Accepted: 7 February 2017

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http://dx.doi.org/10.1177/10538151000230010901

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http://dx.doi.org/10.1111/1751-486X.12092

http://dx.doi.org/10.1111/cch.12246

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