family-centred interventions by primary healthcare
TRANSCRIPT
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
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 Page 2 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
McCalman et al. BMC Pregnancy and Childbirth (2017) 17:71 Page 3 of 21
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
McCalman et al. BMC Pregnancy and Childbirth (2017) 17:71 Page 4 of 21
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
McCalman et al. BMC Pregnancy and Childbirth (2017) 17:71 Page 5 of 21
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
McCalman et al. BMC Pregnancy and Childbirth (2017) 17:71 Page 6 of 21
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.
McCalman et al. BMC Pregnancy and Childbirth (2017) 17:71 Page 7 of 21
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
McCalman et al. BMC Pregnancy and Childbirth (2017) 17:71 Page 8 of 21
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]
McCalman et al. BMC Pregnancy and Childbirth (2017) 17:71 Page 9 of 21
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
McCalman et al. BMC Pregnancy and Childbirth (2017) 17:71 Page 10 of 21
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
McCalman et al. BMC Pregnancy and Childbirth (2017) 17:71 Page 11 of 21
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
McCalman et al. BMC Pregnancy and Childbirth (2017) 17:71 Page 12 of 21
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
McCalman et al. BMC Pregnancy and Childbirth (2017) 17:71 Page 13 of 21
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
✓
McCalman et al. BMC Pregnancy and Childbirth (2017) 17:71 Page 14 of 21
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
McCalman et al. BMC Pregnancy and Childbirth (2017) 17:71 Page 15 of 21
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
McCalman et al. BMC Pregnancy and Childbirth (2017) 17:71 Page 16 of 21
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
McCalman et al. BMC Pregnancy and Childbirth (2017) 17:71 Page 17 of 21
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
McCalman et al. BMC Pregnancy and Childbirth (2017) 17:71 Page 18 of 21
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.
McCalman et al. BMC Pregnancy and Childbirth (2017) 17:71 Page 19 of 21
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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