Developing research capacity building for Aboriginal & Torres Strait Islander Health Workers in health service settings

Introduction: Aboriginal and Torres Strait Islander health workers (hereafter called health workers) can play a major role in facilitating culturally appropriate health care delivery and program development through the acquisition of improved skills in the planning, monitoring and evaluation of these programs (RCB). However, many Aboriginal and Torres Strait Islander people and communities remain concerned about research and related activities. Health workers are well placed to assist communities to not only embrace research, but to be active players and promoters of relevant, appropriate and acceptable research. One means of achieving the twin goals of RCB and community acceptance and involvement in research, is through health workers undertaking research of health priority issues and evaluation of activities, such as program delivery, that are of direct relevance to their community’s aim of improving or enhancing service delivery. This article outlines the development and content of a communitybased RCB framework for health workers. The focus is on the major issues that enhance a proactive service delivery model using culturally appropriate research methods. Development process: The RCB framework described here was developed, over a period of time, through community workshops and consultations aimed at deriving general consensus on the key issues and components of a culturally-appropriate, community-based training process. The framework has subsequently been reviewed by Aboriginal and Torres Strait Islander community representatives from across Australia. The overall aim of the framework is to supplement current (institutionally-based) education and training resources for health workers with community-based research training modules. These modules can be tailored to provide research and evaluation skills relevant to health workers taking a more proactive role in facilitating health and wellbeing programs in their own communities. The use of collaborative consultation and participatory


Introduction
This article outlines the development and content of a community-based research capacity building (RCB) framework for Aboriginal and Torres Strait Islander health workers (hereafter called health workers).The focus is on the major issues that enhance a proactive service delivery model using culturally appropriate research methods.Research capacity building is defined here as a planned, structured approach to increasing health workers' knowledge and skills about research so that they can assess and contribute to research and evaluation activities within their communities.To achieve maximum benefit, this should take place with active community consultation which builds processes and strategies associated with RCB that are both relevant and culturally appropriate for the community involved.
Health workers can play a major role in facilitating culturally appropriate healthcare delivery and program development through the acquisition of improved skills in the planning, monitoring and evaluation of these programs, as recognised in the recent rounds of the National Health and Medical Research Council (NHMRC) Capacity Building Grants in Population Health 1 .Indeed, the National Aboriginal Health   Strategy and, more recently, the NHMRC encourage active involvement of health workers in all phases of planning health initiatives; including needs assessment, development, implementation and evaluation phases, notwithstanding cultural processes including information sharing and ownership, cultural respect for the individual, and the community 2,3 .However, such documents do not provide a framework for training health workers appropriately for these tasks.Additionally, formal course-based education programs for health workers tend to provide rudimentary theoretical overviews of the research process and are institutionally based.The framework described here, and developed through a consensus process with Aboriginal and   Torres Strait Islander communities and representatives, is intended to provide practical, community-based RCB within health workers' own healthcare services and communities.

Background
Among Aboriginal and Torres Strait Islanders, the term 'research' is 'a dirty word' and many Aboriginal and Torres Strait Islander people are wary of research endeavours 4 .
Research involving Aboriginal and Torres Strait Islander people in Australia has a chequered history, particularly in health-related fields, where much research in the past was often poorly designed, non-collaborative and based on cultural and social engineering theories [5][6][7][8] .The impact of these past practices persists today: '…the ways in which scientific research is implicated in the worst excesses of colonialism remains a powerful remembered history for many of the world's colonised peoples' 9 .
In this climate, the process of any research enterprise can be as important as the outcomes, in terms of building firm foundations for future collaboration and projects.Thus, there is considerable benefit for health workers, who generally have strong community credentials and high profile roles within the health workforce, to be more actively involved in developing, delivering and evaluating health programs.However, it is incumbent that health workers have appropriate training and skills for such roles.When, in 2002, we began the consultations and development process that has resulted in the development of the RCB framework outlined here, we found little evidence of RCB training within institutionally-based health worker education programs, which were rightly focused on providing core healthcarerelated knowledge and skills.The apparent lack of culturally appropriate training in research and evaluation methodology, delivered on-site, suggested that health workers were unlikely to be well equipped to fulfil this role.However, the development of national programs such as the Primary Health Care Research, Evaluation and Development (PHCRED) program, which focuses on increasing research capacity across primary health care, presented an opportunity to assist in developing capacity building initiatives specific to the needs of Aboriginal and Torres Strait Islander healthcare organisations and the communities they serve.

Early opportunities and consultation
In 2001, the PHCRED program at James Cook University, Queensland, Australia (PHCRED-JCU), set as its primary Torres Strait Islander health initiatives that were considered by participants to be generally ad hoc.Participants felt that an holistic perspective needed to be adopted because this was considered appropriate to Aboriginal and Torres Strait Islander healthcare delivery and control in primary healthcare services.It therefore appeared that a program aimed at building research capacity in Aboriginal and Torres Strait Islander services, specifically health workers and communities, might best be enacted as an accredited course, which would consist of a series of connected 'topical' modules.To further complement accredited coursework, it was proposed that individualised workshops could be held for those health workers who did not wish to undertake formal training towards another qualification, but did require up-skilling in research and evaluation strategies with practical application in their workplace.The remainder of this article outlines the issues considered to be essential to RCB for health workers and their communities and which will likely enhance a proactive service delivery model using culturally appropriate research methods.We define 'proactive' as leading, or knowledgeably participating, in the planning and delivery of health services.

Guiding principles in the development of the framework
Several core 'principles' underpinned the development of the framework.First, it is well documented that the health status of Aboriginal and Torres Strait Islander people is far below that of the non-Aboriginal and Torres Strait Islander population, and therefore is at the forefront of the national focus on health and service delivery initiatives 10,11 .Second, active Aboriginal and Torres Strait Islander community involvement in health service development, monitoring and improvement is considered essential [1][2][3][4] .Third, Aboriginal and Torres Strait Islander communities should be involved in on-going professional development of health workers in the community context.Fourth, community-based training is most likely to focus on specific learning and skills appropriate to community needs and expectations.
To ensure that we were not 're-inventing the wheel', we undertook a preliminary investigation of RCB opportunities

The research capacity building framework
The framework outlined here (Fig 1 ), is aimed at integrating RCB into education, skills development and practice for Aboriginal and Torres Strait Islander health workers, their communities and their health services.It is designed to be transferable across health service type, location and cultural protocols.Figure 1 displays the core elements required to improve services and their delivery, each of which constitutes a nominal 'module' within the RCB framework.
Some detail about what each element (module) encompasses is outlined below.For efficiency of description, the framework has been depicted as six apparently discrete entities; however, in practice a more eclectic approach to the various issues could be taken in order to best meet the needs of individual health workers and communities.The diagram also demonstrates the cyclical nature of RCB, as a continual review is required of community primary healthcare needs and priorities and the role of service provision in meeting these effectively.Finally, the framework was developed with the intention that it be conducted in the community setting, thus potentially enabling more health workers to participate and gain understanding and skills of direct relevance to their community, through direct application to existing requirements.It is envisaged that, should a health worker seek a formal Vocational Education and Training (VET) award, each module would take approximately one academic semester to complete on a part-time, self-directed (distancelearning) basis.This VET-accredited course framework would draw upon suitable subjects from other VET and university courses to complement those specifically developed here.The underlying premise upon which this framework has been developed is that all coursework needs to be tailored to meet the specific learning requirements of each health worker enrolled in the program.It should be noted that some existing coursework programs are not amenable to 'tailoring' and therefore may not be able to be used in some settings.
Figure 1 illustrates the inter-relationships between individual RCB 'modules' (Boxes 1-6) and their application in defining best practice service delivery.Ideally, if a health worker intended to undertake the entire RCB program, they would most logically progress from Box 1 to Box 6.However, the diagram and checklists for each box enable a health worker to determine the most appropriate place to begin according to their existing knowledge and skills, and their specific need (eg establishment of an evaluation program for an existing service).Regardless of the module at which RCB training begins, the first step always is to detail community input and experiences of existing health services through a general introduction and 'scene setting' session.Additionally, although listed in Box 1, issues pertaining to ethical research practice would also be covered in the introductory session.
For the purposes of explanation, we outline each module in numerical order from Box 1 to Box 6.
The first module (Box 1) focuses on developing an understanding of the key issues and processes involved in 'assessing' Existing Services, some of which are listed in the box.The module addresses the importance and means of identifying current strengths and shortfalls in existing services with specific regard to each community's needs and expectations.Additionally, participants learn a range of options for changing service delivery practices and directions so as to ensure that revisions are culturally appropriate and meet the community's needs.Issues covered include service delivery skills and knowledge, information collection, means of dealing with information shortfalls, information analysis and interpretation, and the need to focus on future service development.The importance of implementing continuous improvement processes and best practice management approaches is also covered.Participants will learn the utility of developing a research checklist specific to their 'research' needs and tailored to match their community's needs, resources and expectations.
The purpose and benefit of the checklist is that it explicitly covers the issues of importance to a community that intending researchers need to know about and also need to complete before research activities begin.It is a form of nonlegal 'contract' between researchers and communities, the purpose of which is to prevent subsequent distress or dispute.
Although, the focus here is on research-related activities, the checklist process could just as easily be used for service providers new to a community.In summary, the aim is not to be scared of research.If it is in our hands and in our control, by people who we want to do the research with, it will make a difference.The next step is to test the RCB framework in the field.
for health workers in 2002 which included searching for dedicated RCB courses, but none of the latter were found.Participants at the 2002 National PHCRED and 2003 PHCRED-JCU Research Workshops reiterated the paucity of formal research training specifically developed for health workers within community-based services and settings.During the period 2003-2005, the framework outlined here was reviewed and refined through meetings with Aboriginal and Torres Strait Islander community representatives from various areas across Australia.The overall aim of the framework is to supplement current education and training resources for health workers with research training modules that can be tailored for individual needs and undertaken in health workers' own communities.The underlying principle of the framework is to ensure that best practices for Aboriginal and Torres Strait Islander communities and services are established and/or maintained, by using culturally appropriate service delivery, monitoring and evaluation methods.The framework enables RCB at both the individual (health worker) and community levels because it focuses on developing skills and knowledge in research and evaluation strategies informed by collaborative consultation and participatory methods.This approach is thus intended as a two-way education process, with the community as an active player.Because Aboriginal and Torres Strait Islander health services and, specifically, the roles and practices of health workers, involve the provision of direct care to individuals, family and the community at large, a community-based learning environment not only encompasses a holistic approach (individual, family, community) to the physical, emotional and social aspects of health, but can also ensure that RCB can be tailored specifically to the needs of the community.By being immediately and obviously of benefit to the community, particularly if the community has been actively involved in the development and implementation of the research/evaluation activity, it is possible that some of the historical concerns about research may be alleviated.Every Aboriginal and Torres Strait Islander community is different, and community members expect that their community will be treated as unique in its own country.Throughout the development of the framework, the principles of conducting research ethically within each community have been paramount.These principles emphasize: …the right to self-determination and to the management and preservation of their culture and heritage.At all stages, research with and about Aboriginal and Torres Strait Islander people must be based on a purposeful and mutually beneficial relationship between researchers and Aboriginal and Torres Strait Islander people.12

Figure 1 :
Figure 1: The research capacity building cycle -using culturally appropriate research methods to achieve a proactive service-delivery model.(Based on J Bailey, oral presentation, 2003).
The second module introduces a range of methods and measures for Identifying Need (Box 2) at the individual, community and service levels.A mixture of needs assessment processes is introduced, but with an emphasis on cultural appropriateness, acceptability and accessibility.Participants would work their way through 'hands on' exercises based on their own communities and experiences.These exercises include information gathering, interpreting and disseminating results, as well as the potential for joint ventures and/or strategic alliances.The third module (Box 3) addresses issues that are important in Program Development, some of which are listed in the box.The module focuses on the 'what is' of program development.The importance of active community participation and its role in setting the 'ground rules' for research (both focus and activities) is emphasised.

Figure 2
Figure 2 is an example checklist that identifies appropriate methods for: preventing poor consultation; lack of communication; and infringement of values arising from cross-cultural insensitivity in services and research.By completing the checklist, researchers are acknowledging the community's specific concerns and requirements.Another element of the checklist is that it ensures that local research capacity needs are identified and tailored to each community.In other words, the research activity also builds research capacity in local people (health workers in this case) through their active participation in all elements of the process.This leads, then, to continuous improvement of

Figure 2 :
Figure 2: Example of a research checklist to ensure culturally appropriate communication and recognition of community sensitivities. ).
♦ Research process ♦ Barriers to participation ♦ Addressing needs and gaps in service ♦ Funding review ♦ Negotiation strategies Discussions with university supervisor on ideas of research.Refer to [resource] or link through university Aboriginal and Torres Strait Islander centre or university research group Establishing community rapport ♦ Allow 6 months (or more) for discussions about intended research ♦ Attend cross-cultural workshop ♦ Link in and network contacts of relevant workers and people within the community ♦ Community consultations with stakeholders or focus groups on a regular basis eg Aboriginal or Torres Strait Islanders or both, male or female, or both.Know who you are targeting, this is important for your contacts.
♦ Have clear knowledge of your intending research, research question and outcomes, and explain this in 'laymen' terms ♦ MOU (memorandum of understanding) of each other's roles during the research process, what the community will get back after the research has finished and who will own the research, outcomes etc ♦ Ongoing monthly contact during the research process Formal application ♦ Ethics application of, for example, university, health department, other health research guidelines (be aware of ethics application due dates) ♦ Copies of formal applications and support documentation to the relevant Aboriginal and Torres Strait Islander service for board meeting (frequency) within the community for support and permission to undertake research [list local Aboriginal Medical Service].[From: 'Nyinan-Binang'-Indigenous Primary Health and Research Group 2005 13 , with permission]