Ironbark: Developing a healthy community program for older Aboriginal people

Abstract Issue addressed Programs by, with and for Aboriginal older people must be culturally safe and relevant. Successful elements include being Aboriginal specific and group based. Co‐design with Aboriginal people and stakeholders is essential. We describe the co‐design process of developing the Ironbark: Healthy Community program. Methods Aboriginal ways of knowing, being and doing and yarning conversational methods guided the development process, during 2018. A desktop review provided details of current group characteristics and key community stakeholders. Stakeholder engagement regarding views about group operations, participants and benefits also occurred. Aboriginal Elders views of their groups were gathered through yarning circles in New South Wales (NSW). Grounded theory approach was used to ascertain key themes. Results Initial engagement occurred with 13 different community stakeholders and organisations in three Australian states (NSW, South Australia (SA), Western Australia (WA)). Three yarning circles occurred with Elders from urban (N = 10), regional coastal (N = 10) and regional country (N = 4) groups. Six key themes were organised in three groups according to an Aboriginal ontology. 1. Knowing: groups provide opportunities to share knowledge and connect socially. Adequate program resourcing and sustainability are valued. 2. Being: groups strengthen culture, providing important social, emotional and other forms of support to age well. 3. Doing: previous program experiences inform perceptions for new program operations. Group venues and operational aspects should be culturally safe, acknowledging diversity among Elders, their preferences and community control. Themes were used to develop the program and its resource manual that were finalised with stakeholders, including steering committee approval. Conclusions Stakeholder feedback at multiple stages and Aboriginal Elders’ perspectives resulted in a new co‐designed community program involving weekly yarning circles and social activities. So what?: Co‐design, guided by Aboriginal ways of knowing, being and doing, can develop programs relevant for Aboriginal people.


| INTRODUC TI ON
Aboriginal peoples are the world's oldest continuous cultures.
Aboriginal Elders are keepers of cultural knowledge, wisdom and are respected, trusted community leaders and educators, passing traditions to younger people and support maintaining connection to Country. 1 These practices are an integral part of Aboriginal cultures. As Aboriginal people age, it is vital that they are enabled and supported to continue as cultural leaders, particularly as Aboriginal people have a lower life expectancy than other Australians, due to structural determinants. 2 A previous study with 76 Aboriginal older adults found that healthy ageing was considered essential to continue to share knowledge of history and cultures, yet Aboriginal people may require greater support at a younger age. 3 To be successful, programs by, with and for Aboriginal Elders must be culturally safe and relevant. 3 Aboriginal-specific, group-based programs with continuity and flexibility have also been identified as important elements. 4 Co-design can be defined as meaningfully involving end-users in research. 5 Co-design with Aboriginal people and community organisations as end-users is essential when developing new programs and research. 6 Implementing and evaluat-stakeholders and Aboriginal Elders in guiding co-design processes is also necessary. 7 A recently developed program and resource manual for Aboriginal Elders, Ironbark: Standing Strong and Tall, aims to prevent falls and was co-designed with Aboriginal communities in New South Wales (NSW). 4 The program was evaluated with six communities and 98 Aboriginal people aged 40-90 years old; significant improvements in strength and balance and reductions in body mass index were achieved. 8 There was also a noticeable increase in participants becoming involved with social activities and outings, including walking groups. All participants reported that they enjoyed the program and were willing to recommend it to others, with the yarning circles being the most popular program element. 8 A cluster non-randomised controlled trial is being conducted to test if the Ironbark: Standing Strong and Tall program prevents falls and improves health and well-being among older Aboriginal people, compared to the Ironbark: Healthy Community program (www.ironb arkpr oject.org.au). 9 The trial has strong Aboriginal leadership takes place in NSW as well as in South Australia (SA) and Western Australia We describe the co-design process of developing the Ironbark: Healthy Community program with community stakeholders and older Aboriginal people.

| ME THODS
Indigenous research methodology adopts Aboriginal ways of knowing, doing and being. 10 Yarning circles are an Aboriginal research method for conversation that involves storytelling and knowledge sharing. 11 Yarning has been used in Aboriginal communities for thousands of years and is central to building respect, learning from each other equally and preserving cultural knowledge and tradition. 11 The two-phased development process occurred during 2018, conducted by Aboriginal researchers in NSW. First, a desktop review was conducted to identify information about existing groups and services for Aboriginal Elders including their funding sources, focus, operational details and locations. Key community stakeholders and organisations in NSW, SA and WA involved with groups were identified through this review, and existing community relationships.
Using purposeful sampling, 12 stakeholders were invited to share their experiences in a semi-structured telephone or face to face interview, depending on travel feasibility and were asked a series of six questions about their group operations, participants and perceived benefits (Table 1).
Second, stakeholders with Elders groups were also asked if they would be interested in inviting their Elders to participate in yarning   Three group yarning circles were conducted between July and September 2018. One group was in an urban area (N = 10); two groups were in regional areas, one coastal (N = 10) and one country (N = 4). Six key themes emerged from the yarning groups. These themes, grouped within three categories of knowing, doing and being, 10 with supporting quotes are presented in Figure 1.

| DISCUSS ION
We report on the co-design process of developing the Ironbark: Healthy Community program. The program aims to provide older Aboriginal

Knowing
Holistic wellbeing activities that are wide ranging in nature that provide opportunities to learn and share knowledge, and also value opportunities as a group (Theme 1) ics of relevance to them and their communities. 9,13 The weekly program involves a 1-1.5-hour yarning circle and/or other social activity.

'A good while now, Yeah. Last year (keep it) going, we come in, we sit down and have a yarn around the table and we talk, and sometimes it brings out things what we like to do, you know.' Regional coastal community 'I suppose everybody's got different interests. Some people like to do arts and crafts, some people like to do beads and making little things. So everyone's got a little bit of bit of an interest in what they want to do I suppose.' Regional country community -'It's all a social thing -it's all a social thing to do and that companionship and having the same interests as everybody in the group and socialisation.'
Participating sites will receive the manual, training, and support, including two paid positions to coordinate the group and deliver the program.
The manual provides guidance on conducting yarning circles, ideas for different types of activities and example education sessions, whilst giving choice to the group. It is a living document that can be updated with feedback from implementation by groups, providing the opportunity for ongoing co-design, reflecting experiences of Aboriginal Elders.
A recent study of the adaptation of an early childhood program for Aboriginal and Torres Strait Islander people noted the importance of community consultation and building relationships, 14 that were also essential in the development of this program. Co-design with Aboriginal communities is increasingly used in program and resource development. 6 Similar approaches have recently engaged Aboriginal youth and an Aboriginal reference group to design a pre-conception learning resource 15 and Aboriginal people living with a disability to co-design a toolbox of activities and associated program. 16 Community collaboration and Aboriginal research methodological approaches are vital to ensure cultural safety and relevance. 17 We used Indigenous research methods, specifically Aboriginal ontology of knowing, doing and being, 10 and yarning with Aboriginal Elders to gain their perspectives of important program elements. 11 These ontology concepts are both distinct and may overlap; this was evident in the six themes that arose from the yarning circles with Elders that were broadly consistent with stakeholder views. Beyond using these findings in program development, the yarning circle themes Elders remain strong yet face multiple challenges in their lives and in the ability to age well and community groups provide important social support and relief, and support to be healthy (Theme 4) - Strengths include Aboriginal leadership in all processes, yarning circles and community-controlled stakeholder engagement directly informing the program and resource development. A limitation is a lack of opportunity to revisit the regional groups for feedback on the resulting program and manual, however ongoing informal discussions occurred with the urban group and other stakeholders.

| CON CLUS ION
The Ironbark: Healthy Community program was developed through a co-design process that included stakeholder feedback at different stages and perspectives from Aboriginal Elders. Gaining insights from future experiences of Elders groups regarding program implementation and manual use will be valuable to learn about its impact and to inform future program planning.

K E Y WO R DS
Aboriginal and Torres Strait Islanders, ageing, community-based intervention, older people, participatory action research

ACK N OWLED G EM ENTS
We would like to acknowledge the Elders and Aboriginal community

CO N FLI C T O F I NTE R E S T
The authors declare no conflict of interest.