Strengthening health promotion and research in practice: the experiences of an Aboriginal community controlled health service

Introduction: Health promotion is recognised as an essential element of comprehensive primary health care. Primary health care organisations in Australia need to increase their capacity to deliver health promotion to reduce the growing burden of disease. Aboriginal Community Controlled Health Services (ACCHS) have been identified as ideal models for integrating clinical care, health promotion and community capacity building into primary health care services. Yet very little is known about how health promotion is practised, and what the enablers and barriers to health promotion practice are in an ACCHS. Methods: The aim of this research was to explore how health promotion is practised and how it can be strengthened in an ACCHS. A mixed methods research design was used in this research, with a Participatory Action Research (PAR) approach. Using this approach, participants were actively involved in deciding the focus of knowledge generation, in collecting and analysing information and in taking action to address the priorities identified. Participants were staff at Apunipima Cape York Health Council, an ACCHS located in Cairns, Australia. The thesis contains seven papers (three published, two in press, the remainder are under review). Paper one is a narrative literature review that identified the enablers and barriers to building health promotion capacity in health organisations. Paper two describes the steps the candidate undertook to establish and maintain a research partnership with an ACCHS. Papers three to seven report on the findings drawn from each of the five PAR cycles. Multiple data collection methods were used and included cross-sectional surveys, semistructured interviews and document analysis. A pre- and post-workforce survey (electronic) was conducted in cycle one and five. Qualitative and quantitative data were collected to explore how health promotion is practised in the organisation, attitudes to health promotion in a primary health care context, confidence to perform health promotion and staff's perceived enablers and barriers to health promotion work. The second PAR cycle focused on workforce development to build health promotion evaluation capacity. Qualitative and quantitative data were collected via surveys (electronic) to assess staff confidence, satisfaction, and usefulness of the workshop series and mentoring support. The third PAR cycle explored how health promotion practice was captured and reported in the organisation. Semi-structured interviews were conducted with staff using a purposive sampling approach. Organisational documents such as operational, business and team plans, quality standards, reporting requirements and templates used by staff for reporting health promotion practice were reviewed. The combination of staff interviews and document analysis was used to triangulate the findings. The fourth PAR cycle explored how staff accessed skill development and expertise in health promotion to assist their work practice. Semi-structured interviews were conducted using a purposive sampling technique. The fifth PAR cycle repeated the baseline survey and in addition explored changes staff had noticed over the previous year. Results: Staff in this ACCHS valued the role health promotion practice provides as part of comprehensive primary health care. Participants demonstrated a good understanding of and described practising health promotion at both individual and population levels. However, a number of areas were identified where health promotion practice could be strengthened. These areas focused on: workforce development in evaluating and sharing findings of health promotion projects; improving the way health promotion practice is captured and reported to decision-makers; and, understanding and formalising how staff access health promotion skill development and expertise. As a result of this research, there were a number of changes to health promotion workforce and organisational practice. Changes included: an increase in skilled staff to complete health promotion project evaluations and document work for publication in peer-reviewed journals; updated project planning and evaluation templates; an increase in staff sharing their health promotion project outcomes with other staff, community members and peers at conferences; the development of strategic documents detailing activity aimed at individual and at population levels; and the development of new organisational performance indicators to capture the impact of health promotion practice. As a result of these changes, staff were significantly more confident in the organisation's ability to lead health promotion practice in 2016 compared to 2015. Discussion: By identifying and understanding what influences health promotion practice, strategies can be put in place to strengthen practice. PAR provided practice-based evidence on how health promotion is practised and what influences this practice. By basing the researcher within the organisation and involving the workforce in identifying priorities to action, the researcher was able to understand the work context and current influences on practice, tailor strategies to the current enablers and address the gaps specific to this workplace. Through the research process, the scope of health promotion practice that was already occurring became more visible in the organisation. The organisation was able to identify ways that health promotion practice could be strengthened through changes to workforce and organisational practice. The primary health care workforce needs to be skilled and knowledgeable in health promotion practice and needs the organisational support in place to effectively work at individual and population levels. Having the skills and capacity to share health promotion learnings with other staff, with community members, with other colleagues, and importantly, with decision-makers advances understanding of how health can be improved in disadvantaged populations such as those in Cape York. The research also identified a number of external influences that affect the capacity of the organisation to practice health promotion. National and state leadership, investment in resources for health promotion practice, and the development of individual and population measures are needed to increase the capacity and capability of health promotion practice. Conclusion: The research conducted within this ACCHS is the first study of its kind and provided practice-based learning and insights into how health promotion capacity can be strengthened in an ACCHS. The research aligns with current national policies that identify a need to increase health promotion and prevention approaches in primary health care. A number of recommendations for future research, policy and practice have been made that will increase health promotion practice in Indigenous primary health care settings