Implementing health promotion tools in Australian Indigenous primary health care

Implementing health promotion tools in Australian Indigenous primary health care Abstract Background In Australia, significant resources have been invested in producing health promotion best practice guidelines, frameworks and tools (herein referred to as health promotion tools) as a strategy to improve Indigenous health promotion programmes. Yet, there has been very little rigorous implementation research about whether or how health promotion tools are implemented. This paper theorizes the complex processes of health promotion tool implementation in Indigenous comprehensive primary healthcare services. Methods Data were derived from published and grey literature about the development and the implementation of four Indigenous health promotion tools. Tools were theoretically sampled to account for the key implementation types described in the literature. Data were analysed using the grounded-theory methods of coding and constant comparison with construct a theoretical implementation model. Results An Indigenous Health Promotion Tool Implementation Model was developed. Implementation is a social process, whereby researchers, practitioners and community members collectively interacted in creating culturally responsive health promotion to the common purpose of facilitating empowerment. The implementation of health promotion tools was influenced by the presence of change agents; a commitment to reciprocity and organizational governance and resourcing. Conclusion The Indigenous Health Promotion Tool Implementation Model assists in explaining how health promotion tools are implemented and the conditions that influence these actions. Rather than simply developing more health promotion tools, our study suggests that continuous investment in developing conditions that support empowering implementation processes are required to maximize the beneficial impacts and effectiveness of health promotion tools. Indigenous, Aboriginal, health promotion, empowerment, transfer, spread, implementation, primary health care INTRODUCTION Closing the significant gaps in health and wellbeing equity between Indigenous and non-Indigenous populations is one of the greatest global challenges. Despite Australia’s world-class health system, the life expectancy of Aboriginal and Torres Strait Islander peoples (respectfully referred to hereafter as Indigenous Australians) is estimated to be ∼10.6 years lower for Indigenous males and 9.5 years lower for Indigenous females than that for non-Indigenous males and females, respectively (Australian Institute of Health and Welfare, 2015). There is a growing body of evidence, however, that with sustained and concerted efforts, health promotion can reduce the greater Indigenous burden of preventable illnesses and conditions compared with other Australians (Anderson and Thomas, 2006; Demaio et al., 2012). Health promotion, defined as the process of enabling people to increase control over the determinants of health and thereby improve their health (World Health Organization, 1986), can contribute to health equity and social justice through empowering responses. Empowerment involves both processes and outcomes that generate change at multiple levels—individual, organizational and community—strengthening the capacity for collective action to influence social situations positively (Wallerstein, 1992). It entails the ability of people to assert and claim their legitimate rights in any given situation, and their capacity to accept and willingly discharge responsibilities towards themselves, others and society (Tsey, 2009). Pat Anderson, the Chairperson of Australia’s Indigenous Health Research Centre, the Lowitja Institute, recently argued that empowerment or ‘the control factor’ is central to closing the gap in health and wellbeing equity between Indigenous and other Australians. She stated ‘any policy or programme aimed at reducing the disadvantage of our communities must from its conception through to its implementation and beyond, ask itself how it will increase the ability of Aboriginal people, families and communities to take control over their own lives’ (Anderson, 2014). The desire to close the health and life expectancy gap between Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians has led government and non-government organizations to invest considerably in the development of health promotion tools (McCalman et al., 2014). Indeed, health promotion tools, including those developed specifically for Indigenous Australian populations, are widely available, as evidenced by the more than 1900 health promotion tools identified in a recent scoping study (Wise et al., 2012). McCalman et al. (McCalman et al., 2014) define health promotion tools as structured (often step-by-step) guidelines, instruments, packages and resources designed for improving the planning, implementation and evaluation of Indigenous health promotion programmes or improving existing ones. These health promotion tools differ from other health promotion and education materials, such as posters, pamphlets and flipcharts, which are designed and used primarily to explain a health issue or procedure and written in non-technical language for patients or the broader public. Despite wide production and availability of health promotion tools, however, there has been very little rigorous research about how health promotion tools are implemented (McCalman et al., 2014). Importantly, health promotion tools will have limited scope to achieve their intended impact if they are poorly implemented. Implementation refers to the processes by which an innovation is assimilated into use within an organization (Damschroder et al., 2009). Previous studies have found Ovretveit’s (Ovretveit, 2011) typology of implementation useful for describing and identifying different approaches in Indigenous health programme implementation (McCalman, 2013a, McCalman et al., 2012). Ovretveit (Ovretveit, 2011) argues that implementation can occur through (i) a hierarchical, centrally driven and controlled process; (ii) a more decentralized and participatory adaptive approach supported by experts or (iii) an informal and largely uncontrolled grass roots process whereby organizations define their problems and search for ‘packaged solutions’ which they can adapt to address local needs. To optimize the potential of health promotion tools to reduce Indigenous disadvantage, it is important to develop an understanding of how tools are implemented and how they could be more effectively implemented. Study background and aims The work presented in this paper resulted from a collaboration between researchers based in three Australian universities (located in Brisbane, Melbourne, Cairns and Darwin campuses), as part of a health promotion initiative funded by Australia’s National Institute for Aboriginal and Torres Strait Islander Health Research, the Lowitja Institute. In 2011, the Lowitja Institute held a collaborative workshop for researchers, policy makers, practitioners and community members to establish a project aimed at improving knowledge and understanding about the uptake and implementation of tools to strengthen health promotion in Indigenous comprehensive primary health care (PHC) services. The Lowitja Institute describes Indigenous comprehensive PHC services as services that take a holistic view of health, delivering health care in accordance with principles of PHC as embodied in the Declaration of Alma-Ata (World Health Organisation, 1978). To strengthen the evidence-base for health promotion in Indigenous comprehensive PHC services, the Lowitja Institute adopted a phased approach. Stage 1 was a scoping study of Indigenous health promotion tools (Wise et al., 2012). In Stage 2, the current author team systematically examined the characteristics, implementation and effects of 74 Indigenous health promotion tools. We found a lack of attention to how tools were implemented in practice (McCalman et al., 2014). From previous work, we were also aware of the lack of theoretical conceptualizations about how health innovations are implemented in the Australian Indigenous context, with most being programme specific (McCalman et al., 2012). To address this gap in the literature, and to build on our Stage 2 findings, this paper reports on the development of an Indigenous health promotion tool implementation model. The key study objective was to theorize the processes including the conditions, strategies and outcomes through which health promotion tools are implemented in Indigenous comprehensive PHC services. METHODS Study design To explain and theorize implementation, we examined how tool facilitators go about implementing health promotion tools, why tools are being implemented and with what outcomes. Constructivist grounded theory was chosen as the most suitable method because of the intent to build an applied theoretical model from the practical experience and knowledge of those directly involved in the phenomena under study; and because of its appropriateness for Australian Indigenous settings (Bainbridge et al., 2013; Birks and Mills, 2011; Charmaz, 2006). Secondary data were used to theorise implementation processes and construct the model. Secondary data in grounded theory is defined as ‘any data collected in the past for purposes not originally related to the current study’ (Bainbridge et al., 2013). The advantage of using such data collected from earlier studies is that it saves time, money and other resources (Birks and Mills, 2011). In particular, in the context of Australian Indigenous health research, the use of secondary data avoids unnecessary data collection from Indigenous people who have been traditionally over-researched (Bainbridge et al., 2015; Whiteside et al., 2012). Sampling health promotion tools and data sources Researchers, practitioners, policy makers and community members attending the collaborative workshop organized by the Lowitja Institute (described above) identified health promotion tools from the results of the Stage 1 scoping study (Wise et al., 2012). Two criteria guided the selection process: (i) the tools must be designed specifically to strengthen programmes aimed at improving Indigenous Australian or other Indigenous population’s health and wellbeing; and (ii) implemented in Indigenous comprehensive PHC services. This resulted in the identification of three health promotion tools: (i) the Continuous Quality Improvement tools in health promotion (HPCQI); (ii) the Family Wellbeing (FWB) community education empowerment programme; (iii) the tool for monitoring the ecological approach of health promotion programmes [the Ecological Coding Procedure (ECP) and its associated data collection instrument as used in the Creating Healthy Environments (CHE) and other health promotion evaluation projects in Victoria]. A fourth tool, the Community Health Action Pack (CHAP), was subsequently included in the study after our data analysis revealed a theoretical gap in the initial sample of tools (described below). Data sources for the current study were identified by requesting nominations of grey and published reports from people involved in the development, implementation and/or evaluation of the health promotion tools and by reviewing publicly available documentation about the tools. In grounded theory, data collected via such a selective sampling process has been referred to as tentative theoretical ‘jumping-off point’ from which to begin theory development (Thompson, 1999). Through discussion and consensus among the current author team, nine reports and publications were selected (Doyle et al., 2013; Johnston et al., 2013; McCalman, 2013a, 2013b; O'Donoghue et al., 2014; Percival, 2014; Reilly et al., 2007, 2008, 2011). These data sources were chosen on the basis that they provided the richest and most relevant information about the development and implementation of the health promotion tools and in turn, were the data sources that would yield the strongest empirical concepts for constructing a theoretical model (Draucker et al., 2007). A brief description of the four health promotion tools, implementation type, the organizations where tools were implemented and data sources used for this study are provided in Table 1. Table 1: Health promotion tools: descriptions, aims, implementation settings and study data sources Tool/implementation type  Tool description and aims  Where implemented  Data sources  Family Wellbeing Program (FWB)—Facilitated evolutiona  A generic personal and community empowerment programme that is consistent with healing approaches for Indigenous peoples. FWB provides the tools for participants to create their own outcomes, which leads to a broad range of effects in participants’ health, employment, education, parenting, relationships or whatever is relevant for the person at that time. FWB was developed by Indigenous people, for Indigenous people.  Diverse implementing organizations (including government, non-government, private and academic entities) geographically located in 56 sites across Australia  Peer-reviewed paper (McCalman, 2013b) A PhD thesis based on in-depth interviews with Aboriginal and non-Aboriginal research respondents who had been active in transferring the programme across Indigenous communities and healthcare settings (McCalman, 2013a).  Ecological Coding Procedure (ECP)—Facilitated evolutiona  A systematic tool to describe and capture the degree of integration of the ecological perspective in health promotion programmes. Originally developed for application to mainstream health promotion programmes in Canada and modified to monitor health promotion programme implementation in a Mohawk community. The tool has also been tailored for use in an Indigenous community as part of the CHE project in Victoria, Australia.  Three community based organizations located in the semi-urban Goulburn-Murray region of northern Victoria, Australia.  Peer-reviewed papers (Reilly et al., 2007, 2008, 2011; Doyle et al. 2013; Johnston et al., 2013).  Health Promotion Continuous Quality Improvement (HPCQI)—Participatory adaptationb  A structured and facilitated approach to assist primary health care centres strengthen their health centre systems and improve development and delivery of health promotion activities that meet the needs of their local population. CQI tools enable the systematic collection of information to determine the extent to which delivery of health promotion and health centre systems align with best practice. When repeated, changes in practice and systems and explanations for those changes, can be monitored over time. HP CQI was adapted from existing CQI tools and processes in response to demand from primary health care services  Four Indigenous primary health care services in the Northern Territory, Australia.  Peer-reviewed paper (O'Donoghue et al., 2014). A PhD thesis based on assessments of practice records and semi-structure group interviews with Indigenous and non-Indigenous staff of four Northern Territory primary health care services involved in the development and implementation of the CQI tools (Percival, 2014).  Community Health Action Pack (CHAP)—Hierarchical controlc  CHAP was developed as part of the Local community campaigns to promote better Aboriginal and Torres Strait Islander health programme, a measure under the Australian Government's Indigenous chronic disease package (ICDP). The CHAP includes templates, examples, checklists and tips to help with planning a health promotion project. The CHAP is designed to be flexible so that communities and organizations can use it to suit their own needs, in particular the CHAP was used to support newly established ICDP Healthy Lifestyle workforce. Organizations receiving funding for Healthy Lifestyle Workers were provided copies of the CHAP.  24 primary health care services across Australia, spanning rural, remote and regional areas.  A government report based on semi-structured interviews with Indigenous Healthy Lifestyle workers (predominately Aboriginal Tobacco Action Workers, Healthy Lifestyle Workers and Regional Tobacco Coordinators) clinicians and health centre managers working in Indigenous and mainstream primary health care services across Australia who were involved in using the CHAP to design and deliver healthy lifestyle programmes with their local community (Bailie et al., 2013).  Tool/implementation type  Tool description and aims  Where implemented  Data sources  Family Wellbeing Program (FWB)—Facilitated evolutiona  A generic personal and community empowerment programme that is consistent with healing approaches for Indigenous peoples. FWB provides the tools for participants to create their own outcomes, which leads to a broad range of effects in participants’ health, employment, education, parenting, relationships or whatever is relevant for the person at that time. FWB was developed by Indigenous people, for Indigenous people.  Diverse implementing organizations (including government, non-government, private and academic entities) geographically located in 56 sites across Australia  Peer-reviewed paper (McCalman, 2013b) A PhD thesis based on in-depth interviews with Aboriginal and non-Aboriginal research respondents who had been active in transferring the programme across Indigenous communities and healthcare settings (McCalman, 2013a).  Ecological Coding Procedure (ECP)—Facilitated evolutiona  A systematic tool to describe and capture the degree of integration of the ecological perspective in health promotion programmes. Originally developed for application to mainstream health promotion programmes in Canada and modified to monitor health promotion programme implementation in a Mohawk community. The tool has also been tailored for use in an Indigenous community as part of the CHE project in Victoria, Australia.  Three community based organizations located in the semi-urban Goulburn-Murray region of northern Victoria, Australia.  Peer-reviewed papers (Reilly et al., 2007, 2008, 2011; Doyle et al. 2013; Johnston et al., 2013).  Health Promotion Continuous Quality Improvement (HPCQI)—Participatory adaptationb  A structured and facilitated approach to assist primary health care centres strengthen their health centre systems and improve development and delivery of health promotion activities that meet the needs of their local population. CQI tools enable the systematic collection of information to determine the extent to which delivery of health promotion and health centre systems align with best practice. When repeated, changes in practice and systems and explanations for those changes, can be monitored over time. HP CQI was adapted from existing CQI tools and processes in response to demand from primary health care services  Four Indigenous primary health care services in the Northern Territory, Australia.  Peer-reviewed paper (O'Donoghue et al., 2014). A PhD thesis based on assessments of practice records and semi-structure group interviews with Indigenous and non-Indigenous staff of four Northern Territory primary health care services involved in the development and implementation of the CQI tools (Percival, 2014).  Community Health Action Pack (CHAP)—Hierarchical controlc  CHAP was developed as part of the Local community campaigns to promote better Aboriginal and Torres Strait Islander health programme, a measure under the Australian Government's Indigenous chronic disease package (ICDP). The CHAP includes templates, examples, checklists and tips to help with planning a health promotion project. The CHAP is designed to be flexible so that communities and organizations can use it to suit their own needs, in particular the CHAP was used to support newly established ICDP Healthy Lifestyle workforce. Organizations receiving funding for Healthy Lifestyle Workers were provided copies of the CHAP.  24 primary health care services across Australia, spanning rural, remote and regional areas.  A government report based on semi-structured interviews with Indigenous Healthy Lifestyle workers (predominately Aboriginal Tobacco Action Workers, Healthy Lifestyle Workers and Regional Tobacco Coordinators) clinicians and health centre managers working in Indigenous and mainstream primary health care services across Australia who were involved in using the CHAP to design and deliver healthy lifestyle programmes with their local community (Bailie et al., 2013).  a Facilitated evolution (or grass roots approach) focuses on assisting communities identify local priorities and locate practices and models to suit their needs, rather than adapting a model that has been imposed. b Participatory adaptation relies on the replication of models across locations, allowing for decentralized decision-making by providing local support for communities to make local adaptations. c Hierarchical control (often conceptualized as ‘push’ or ‘top down’ approach) occurs when a practice or model effective in one location is identified and then replicated at other locations, often with directive detailed plans (Ovretveit, 2011). Data analysis The selected data sources were imported into NVIVO 10. Initial readings of the data sources provided the author team with an overview of each tool and its purpose, the implementation processes and contextual factors. We collated key or main points from each data source by coding text line-by-line. The codes arising out of each data source were constantly compared against codes, firstly from data sources for the same tool, and then data sources from other tools to identify theoretical constructs (Graffigna, 2009). The constant comparison method was applied to group codes into higher-order concepts and repeated until higher-order categories and their relationships were identified (Kelle, 2007). As theory development progressed, a gap in the initial sample of tools was identified. Consistent with grounded theory methods, theoretical sampling was used whereby initially sampling was purposive, with later sampling directed by concepts arising from the evolving theory (Birks and Mills, 2011). Only two of the three types of implementation approaches (participatory adaptation and facilitated evolution) were included; a tool that reflected hierarchical control or a ‘top down’ implementation approach was not represented (Ovretveit, 2011). Ovretveit (Ovretveit, 2011) argues that ‘top down’ implementation ‘is the traditional approach used by ministries of health or large non-government organizations, which delegate and direct lower regional levels and facilities under their control to carry out specific changes’ (p. 242). To address this gap, we sought examples of government-funded, developed and/or centrally driven Australian Indigenous health promotion tools. Two impact evaluations of government implemented tools (Hearn et al., 2011; Hunter et al., 2004) were identified in our previous literature review (McCalman et al., 2014). However, we were also aware of a more recent evaluation of a large scale nation-wide initiative, The Indigenous Chronic Disease Package (ICDP), to which two of the authors of this paper had contributed (Bailie et al., 2013). The ICDP included an unprecedented investment in Indigenous Australian health promotion, including the development of the CHAP. The CHAP was designed to support planning of health promotion programmes with Indigenous communities (Department of Health and Ageing, 2011). The CHAP was included as the fourth health promotion tool as it met the inclusion criteria and filled the theoretical gap in tool sampling. The author team met face-to-face to construct the final theoretical implementation model. With sensitivity to the possibility that the analysis may be Western-centric (Johnston et al., 2013), Indigenous researchers and practitioners on our author team ensured the analytical interpretations and findings reflected Indigenous perspectives and experiences of implementing and/or evaluating the health promotion tools in Indigenous comprehensive PHC services. The constant comparison method of examining and comparing the concepts continued until we were satisfied that the higher-order categories and their relationships could be modelled in such a way that explained the great majority of the data and until the central concern (core category) of those involved in implementing health promotion tools and the core process that facilitated that concern were identified (Birks and Mills, 2011). The central concern is the category considered the ‘main theme’ or ‘main concern or problem’ for the study participants (Glaser, 1978). Through an iterative analysis process, and consistent with the intent of health promotion, we determined that the tool facilitators’ central concern for implementing health promotion tools was ‘facilitating empowerment’. The resultant model and explanation of why and how health promotion tools were implemented is described and presented below. RESULTS A model of Indigenous Health Promotion Tool Implementation was constructed (see Figure 1). The model incorporates the common purpose for which health promotion tool implementation occurred (facilitating empowerment; inner circle); the conditions that influenced tool implementation (reciprocity, change agents and governance and resourcing; outer circle); processes that represented the interrelated and overlapping practices of implementation (engaging and relating, strengthening capacity, tailoring for diverse groups and settings, and developing and using evidence; intermediate ring); and benefits arising from health promotion tool implementation (lower centre). The components of the model and explanation of the processes that frame the implementation of health promotion tools in comprehensive Indigenous PHC services are presented below. Theoretical terms are italicized. Figure 1: View largeDownload slide Indigenous Health Promotion Tool Implementation Model—facilitating empowerment through culturally responsive health promotion. Figure 1: View largeDownload slide Indigenous Health Promotion Tool Implementation Model—facilitating empowerment through culturally responsive health promotion. Summary of health promotion tool implementation model The research found that implementing health promotion tools was a social process involving researchers, practitioners and community members (herein referred to as tool facilitators) working collectively, within a specific context, over time. The implementation process reflected patterns of dynamic and contingent interactions between: tool facilitators that interact in doing the work of implementing health promotion tools; the health promotion tool itself; and the organizations within which the tool facilitators and tools come together. The work of implementing health promotion tools, that is what tool facilitators do and how, manifested as four processes (engaging and relating, developing and using evidence, tailoring for diverse groups, programmes and settings, strengthening capacity). These four processes are dynamic and interrelated and together reflected a core implementation process of creating culturally responsive health promotion. Three conditions influenced what tool facilitators do and how they work. First, tool implementation required the presence and continuous investment by people who act as change agents. Change agents were individuals with the mind-set and skills set for promoting and supporting individual, organization and community health promotion. The second condition was a commitment to and practice of reciprocity. Reciprocity described the set of values and principles that guide the actions and decisions of change agents and reflected the mutual respect and valuing of the benefits of diversity, dialogue and shared learning. Third, was organizational governance and resourcing; a structural condition that reflects the resourcing, willingness and capability of Indigenous comprehensive PHC services and the associated workforce to do the work of implementing tools. Under favourable conditions, facilitating empowerment through culturally responsive health promotion resulted in benefits including participant satisfaction and control; workforce recruitment and capacity; organizational resources, systems and partnerships; and programme sustainability and spread. Why implement health promotion tools? Facilitating empowerment was the primary reason for implementing health promotion tools in Indigenous comprehensive PHC services. This driving concern was pertinent despite differences in the tool types, focus, theoretical and evidential underpinnings. For tool facilitators, empowerment was about using strategies that generated change at multiple levels—individual, organizational and community—to assist Indigenous people take collective action, control and responsibility in any given situation. Facilitating empowerment was important to tool facilitators because it reflected their desire to act as facilitators or enablers, rather than doers, in supporting Indigenous people, families and communities to understand and use their strengths as the basis for change. This was reflected in a comment by a non-Indigenous co-author during construction of the final theoretical model, explaining the role of the tool facilitator in implementing FWB: Irrespective of whatever is happening, as researchers, how can we develop relationships with people, organisations? How can we find, through those relationships, what people are trying to achieve? Is there a way research can enable and add value, enhance that process? So whether it’s men’s groups, whether it’s women’s groups, whether it’s people trying to establish a community controlled organisation or have the footy club or whatever, is there a role for research to support that? (K. Tsey, 2014, personal Communication, 24 April) How are health promotion tools implemented? The process of health promotion tool implementation occurred through culturally responsive health promotion. Health promotion that was culturally responsive occurred when tool facilitators acknowledged Indigenous knowledge, local culture and social systems as an essential part of the complex implementation environment. Creating culturally responsive health promotion was imperative for ensuring a good ‘fit’ between the health promotion tool and the implementation context. Culturally responsive health promotion was more than culturally tailoring health promotion tools. Critical to working effectively in cross cultural situations was valuing and engaging with traditional expressions of Indigenous culture and modes of knowledge dissemination. Importantly, this meant accounting for and reflecting on the influence of historical and contemporary policies and programmes on the health system itself, including health promotion, given it has been experienced by many Indigenous Australians as an extension of colonization/agent of the state (McPhail-Bell et al., 2016). In practice, culturally responsive health promotion manifested as four inter-related and overlapping processes of: engaging and relating; strengthening capacity; tailoring for diversity in programmes, groups and settings; and developing and using evidence. Engaging and relating The first process, engaging and relating, was about developing and maintaining relationships with individuals, their organizations, and the broader policy and community environments. The way tool facilitators went about implementing health promotion tools was the foundation on which relationships and trust were established. Issues of participation, collaboration and community-direction were considered paramount. By building and elaborating upon existing processes and incorporating capacity building strategies, tool facilitators took a strengths-based approach towards creating social environments and relationships that would support action to progress Indigenous health promotion priorities. This was how tool facilitators went about engaging and relating to empower the community to take control of the implementation process. Reilly et al. (Reilly et al., 2007) explained of ECP that the process ‘…hinges on a power shift: outside professionals no longer attempt to control the development process solely on their own terms’ (p. 40). The process of engaging and relating fostered a safe space for tool implementation and thus was reciprocity in practice. An Aboriginal FWB tool facilitator, reflected: ‘It gives that two-way understanding, that’s what Family Wellbeing does….We’re all at this level of understanding…it gets back to that safe space. It allows that two-way understanding to take place because it’s creating that safe place for dialogue to occur.’ (McCalman, 2013b, p. 5) Similarly, creating a safe space for a quality improvement dialogue between researchers and local practitioners facilitated the implementation of HPCQI tools. The two-way dialogue between researchers and local staff assisted local PHC teams to make sense of their data, understand the extent to which health promotion aligned with best practice, and to identify priorities and plan for improvements (Percival, 2014). Strengthening capacity The second process, strengthening capacity for Indigenous health promotion, was also necessary in the work of implementing health promotion tools. Strengthening capacity was a process for, and an outcome of, implementing health promotion tools. Actions for strengthening capacity were focused at the individual worker and organization levels by improving individual practitioner access to materials and resources; improving individual practitioner knowledge and skills in health promotion; and strengthening and modifying the environment (organizational, community and policy levels) to support Indigenous health promotion. For example, training, mentoring and providing support for Indigenous researchers, workers and community members was a common capacity building strategy, as was facilitating group dialogue. An ECP Aboriginal tool facilitator reflected on the process of strengthening capacity of community members: …we brought together some focus groups to look at nutrition and what it meant to our whole community in the area in which we work. We looked at a range of people from a young age to an older age. We talked about things like, ‘what in the food chain do you understand? What does this meant to you? (Reilly et al., 2008, p. 173) Participatory evaluation methods, featuring a collaborative process between tool facilitators and local teams in creating a shared awareness and understanding of the tool and its purpose, assisted the development of local capacity for implementing the centrally produced CHAP. Early indications of implementation success were shared at both the local and policy levels and, in turn, developed the capacity of individuals and organizations to more independently access resources and address their own health promotion priorities in the future (Bailie et al., 2013). Tailoring for diversity of programmes, groups and settings The third strategy was tailoring for diversity of programmes, groups and settings. Originally developed from different theoretical and evidential underpinnings, each tool required some adaptation and modification to better align with their implementation context. Tool facilitators used iterative processes to tailor for the diversity of programmes, groups and settings. For example, initially developed for application to mainstream health promotion programmes in Canada (Levesque et al., 2005), the ECP had to be modified to better represent and capture Indigenous Australian peoples’ relationships to each other and the world (Rowley et al., 2015). Its use was not intended to change the nature or implementation of Indigenous health promotion, but to allow a more accurate description of community-led programmes. This experience and its collaborative application in retrospective analyses (Johnston et al., 2013) led to the need to modify the theoretical basis of the ECP (Rowley et al., 2015). CQI tools have been most extensively used in the clinical health care context and required modifications in their development and implementation to suit Indigenous health promotion. Once the HPCQI tools were developed, implementation was tailored to cater for the needs of different levels of practitioner and organization health promotion capacity at each Indigenous PHC service. A similar process of tailoring for local circumstances occurred for the nation-wide implementation of the CHAP (Bailie et al., 2013). FWB was also adapted for various settings, issues and target groups, and has been variously delivered as a community development and employment, training and capacity development, health promotion, empowerment research and school education programme (McCalman, 2013b). Developing and using evidence The fourth process, developing and using evidence, entailed first, acknowledging and valuing different sources of evidence and, second, using culturally appropriate means for gathering and synthesizing these different sources of evidence. The source of evidence was considered particularly important because it affected the credibility of the evidence, improved users’ confidence in the utility of the tool and their willingness to apply it to improve Indigenous health promotion. Tools were highly valued by Indigenous people when they were developed and delivered or facilitated by Indigenous researchers. An Aboriginal FWB tool facilitator reflected: Our mob when we hear that it’s been developed by our own people, that’s the only reason why sometimes I think they come along to it. So I think that’s the most critical thing. And that it works of course, but you know, people don’t know that it’s going to work until they’ve done it. But to get them there is, you know, that’s just so so important; that it is developed by Aboriginal people. (McCalman, 2013b, p5) Tool facilitators used participatory methods to gather and synthesize the evidence derived from different sources. For example, an audit and feedback process was used for implementing the HPCQI tools (O'Donoghue et al., 2014). This process enabled practitioners to collect information about local health promotion activities in a standardized and systematic way and compare this with best practice. Recognizing divergent interpretations of evidence from Western and Indigenous perspectives was important for implementing health promotion tools. Johnston et al. (Johnston et al., 2013) found of ECP implementation, that, while non-Indigenous researchers perceived walking groups as an intervention targeting individuals, Aboriginal researchers perceived walking groups as an inherently interpersonal and public activity that fostered closer relationships between individuals, families, the organizations they dealt with and the communities in which they were located. These differences in interpretations highlight the need for integrating local Indigenous knowledge with Western research and practice expertise in the design, implementation and evaluation of health promotion programmes. Developing and using evidence was also seen as a way of gaining credibility for Indigenous health promotion ‘through a white system as well’ (McCalman, 2013a). For example, the ECP tool provided a method for recording, analysing and reporting local health promotion activities in an ecological framework. An ecological framework acknowledges social and emotional determinants of health, including those found to be of specific importance to Indigenous communities, including history, relationship with mainstream, connectedness and a sense of community and individual control (Johnston et al., 2013). The documentation of the nature and aims of Indigenous led health promotion was used to influence funders and decision makers. Conditions influencing implementation Although there was huge diversity in Indigenous comprehensive PHC services, for example, in their geographical location, organizational and associated workforce health promotion capacity, there were common conditions that enabled and/or inhibited what tool facilitators do and how they work, and thus influenced health promotion tool implementation. These three conditions were: the presence of change agents, a commitment to reciprocity; and supportive organizational governance and resourcing. Maintaining relationships and sustaining implementation of health promotion tools required long term commitment of change agents. Trust between researchers, practitioners and community members as tool facilitators had been established over many years, often as a result of dialogue and collaboration on previous projects. This continued investment by change agents was important for realizing the benefits of tool implementation by improving local health promotion activities. For example, having a co-facilitator from the local health centre was important for securing local ownership and implementation of the HPCQI tools. Furthermore, the intensity and sustained engagement of the research team as co-facilitators was found to be a significant factor in closing the evidence-practice gap in the health promotion capacity of PHC practitioners and Indigenous PHC service systems (Percival, 2014). Reciprocity was considered an instructional condition that edifies culturally responsive health promotion; providing guidance for how tools were implemented in each setting and situation. Reciprocity was the set of values and principles that guided the actions and decisions of change agents and reflected the mutual respect and valuing of the benefits of diversity, dialogue and shared learning. Across settings and situations, people brought different perspectives, understandings and assumptions about the value, meaning and benefits of implementing health promotion tools. Reciprocity was necessary for recognizing and valuing these multiple perspectives and for guiding actions and decisions for how tools were implemented in each setting and situation - an important approach for improving the health of Aboriginal and Torres Strait Islander people through research (National Health and Medical Research Council, 2010). In ECP implementation, a commitment to reciprocity was formalized through a memorandum of understanding between participating organizations and the community (Reilly et al., 2007, p. 41). Good organizational governance and adequate resourcing was also an important condition that influenced tool implementation. The funding made available for implementing the CHAP provided for organizational infrastructure and recruiting, and enabled individualized training and support for the establishment of a new Healthy Lifestyle Worker workforce (Bailie et al., 2013). Bailie et al.(Bailie et al., 2013, p. 68) explained how this resourcing helped to validate the role of the healthy lifestyle worker within the broader function of the PHC organization: These structures and processes fostered more support for individual workers and validated their role within the broader function of the organisation. At an organisational level, this required a clear vision of how the measures, including the new workforce, should work and a strategic approach to training, learning and development to achieve a workforce capable of designing and delivering tobacco and healthy lifestyle initiatives based on best available evidence. The limited, short-term and insecure nature of health promotion funding, however, created a barrier to implementation by disrupting employment of workers and making it more difficult for people to stay engaged with activities. For example, in implementing ECP, Doyle et al. note the difficulty for an Indigenous sporting club to obtain funding despite it being a major site through which cultural identity, healthy lifestyles, employment, education and other aspects of health promotion and community development are strengthened (Doyle et al., 2013). Ongoing implementation of FWB programme has also been constrained by a lack of funding and resourcing. ….to try and get that level of sustainability is quite difficult for a program of the sort we’re talking about, very difficult really. If you look across the public sector programs…which are non-mainstream, to survive 10 years is quite a challenge, when you’re looking at….at least three governments in a period of time like that. (McCalman, 2013b, p. 7) Benefits of tool implementation Health promotion tool implementation resulted in benefits at individual, workforce and organization levels. At the individual level, people noted they felt satisfied and in control of implementation processes. For example, a PHC practitioner commented on their satisfaction with the CHAP implementation processes saying that it was the first time in a government programme they’d been asked ‘how we were going and what does this mean for us’ and ‘not do a tick box’ (Bailie et al., 2013). Furthermore, (Reilly et al., 2007, p. 173) noted of community member’s involvement in implementing ECP: so they put those things on the table themselves and we never even stated that to them; they did it for themselves. So they did want to know about it, but they wanted to take control and do it themselves The way tool facilitators went about implementing health promotion tools also resulted in strengthened health promotion workforce and organizational capacity. For example, the combination of local and external facilitator knowledge in HPCQI implementation was important for interpreting results and exploring relationships between local practice and what was recognized as best practice. By improving health centre information systems, health promotion evidence was developed through better documentation of local activities that were previously ‘invisible’. This process also translated to improvements in practitioner knowledge and understanding of health promotion and strengthened organizational capacity for health promotion (O'Donoghue et al., 2014). Similarly, the resourcing through the ICDP created favourable conditions for implementing the CHAP: ICDP not only increased capacity of organisations by increasing the number of positions but through developing the knowledge and skills of a new workforce, and through improving health promotion capacity among the existing workforce (Bailie et al., 2013, p.69) In turn, programme sustainability and spread was observed in the implementation of ECP as a benefit from strengthened health promotion capacity. The implementation strategies were participatory in that it was conceived by the participants themselves, and has been embraced enthusiastically by participants, who are now lobbying on their own behalf for the continuation of the group and the provision of appropriate resources (Reilly et al., 2007, p. 44) POTENTIAL LIMITATIONS Challenges arose for our analysis from the use of secondary data sources. The opportunity to interrogate aspects of the tools’ implementation was limited by the descriptions provided in the available reports and publications. Secondary data also limited the flexibility necessary for true theoretical sampling (Birks and Mills, 2011). We considered that given the lack of descriptions about implementation processes reported in the published and grey literature (McCalman et al., 2012, 2014), the inclusion of additional secondary data about health promotion tools was unlikely to provide us with information that would add substantially to our implementation model. Instead, we drew on our involvement in the development, implementation and/or evaluation of the four tools (as well as in the primary data collection and analysis) coupled with our in-depth knowledge of Indigenous health promotion in comprehensive PHC services more broadly, to validate assumptions and propositions in data analysis and construction of the theoretical model. DISCUSSION Drawing from studies of four health promotion tools, we conceptualise implementation as a social process, whereby researchers, practitioners and community members interact in creating culturally responsive health promotion with the common purpose of facilitating empowerment. The impetus of facilitating empowerment reiterates the key function of health promotion, defined as the process of enabling people to increase control over the determinants of health (World Health Organization, 1986) and is consistent with health promotion core values and ideals (Berry et al., 2014; Tsey, 2009). Importantly, this study expands our understanding of how to implement health promotion in the context of Indigenous health. The lack of health promotion success in Indigenous communities has been criticized because it fails to account for the importance of local cultures and continues to have minimal emphasis on capacity building, community empowerment and local ownership (Demaio et al., 2012). Furthermore, efforts to address these criticisms have emphasized strengthening individual practitioner capabilities with less focus on strategies to address health service and broader system factors (Freeman et al., 2014). Indigenous Australians have been long arguing for control over their own affairs and for greater investment in strategies that not only strengthen their own capacity for collective action but also that of government, service systems, organizations and the workforce to generate change and influence social situations positively (New South Wales Health Department, 2002; Tsey et al., 2010). Our implementation model acknowledges that empowerment is not a straight forward concept but a multi-level construct that encompasses strategies for enabling individual, organizational and community-level change. Paradoxically, health promotion tool implementation does not reflect the seemingly linear ‘structured, often step-by-step’ instruction as implied by definition (McCalman et al., 2014). The means of making health promotion tools freely available through websites or sending copies through the mail, as has been identified as the most common strategy for disseminating health promotion tools (McCalman et al., 2014) may not be the most effective way for attaining maximum benefits of health promotion tools. Our study suggests that rather than simply developing more health promotion tools, continuous investment in change agents, a commitment to reciprocity, and adequate and sustainable funding and resourcing, are required to support implementation and maximize the beneficial impacts and cost effectiveness of health promotion tools. A number of studies have demonstrated that the implementation approach or methods for facilitating the delivery of Indigenous health services or programmes affects success (Bailie et al., 2013; Gardner et al., 2010; Hunter et al., 2004). Furthermore, other international models and theories of implementation highlight that implementation success is influenced by facilitation methods or implementation processes (Damschroder et al., 2009; Kitson et al., 2008). Yet, the motivations of implementation are lacking attention or are not given explicit consideration. Similarly, in the health promotion field, values and principles, including equity, empowerment and participation, are central yet intrinsic concepts that are not often made explicit or questioned in every day practice (Berry et al., 2014). Working to change or improve people’s social realities is value laden. Clearly, to optimize the utility of Indigenous health promotion tools, and other Indigenous health innovations, requires thoughtful analysis of not only what we do, but how and why. Implications for health promotion policy and practice The concept of empowerment is central to the work of health promoters, yet a major challenge facing the health promotion field is understanding what this means and how it shapes everyday policy and practice (Berry et al., 2014; Tsey, 2009). Table 2 outlines examples of how tool facilitators can go about implementing health promotion tools to enable Indigenous people to increase control over and to improve their health and wellbeing. Derived from our theoretical model, and identified by the author team, we offer these as practical examples of culturally responsive health promotion for potential use by other tool facilitators. Table 2: Processes of culturally responsive health promotion to facilitate empowerment Culturally responsive health promotion  Strategies of culturally responsive health promotion  Engaging and relating  Listening and responding to input and feedback Making connections with the community by involving key members of the community and recruiting local people Feeding back to community Disseminating and sharing ideas through structured communication channels such as committees and decision making groups and informal channels such as word-of-mouth Linking with partner organizations  Strengthening capacity  Training, mentoring and supporting individuals and teams and aligning with workforce competencies Accessing resources by making available online Influencing and/or obtaining funding support Enhancing cultural competencies by promoting/developing multidisciplinary linkages Suggesting alternative ways to improve programmes and research processes  Tailoring for diverse groups and settings  Adapting tools for delivery with different groups in different places, settings and situations Being flexible in design and delivery Working and learning cross culturally Recognizing gender differences and tailoring for different participant needs  Developing and using evidence  Using participatory evaluation methods Using cultural frameworks to develop and build an evidence base Recognizing limitations (and often harm) associated with use of western frameworks and research processes Acknowledging and valuing different sources of evidence including Indigenous knowledge Building on past programme experiences and lessons  Culturally responsive health promotion  Strategies of culturally responsive health promotion  Engaging and relating  Listening and responding to input and feedback Making connections with the community by involving key members of the community and recruiting local people Feeding back to community Disseminating and sharing ideas through structured communication channels such as committees and decision making groups and informal channels such as word-of-mouth Linking with partner organizations  Strengthening capacity  Training, mentoring and supporting individuals and teams and aligning with workforce competencies Accessing resources by making available online Influencing and/or obtaining funding support Enhancing cultural competencies by promoting/developing multidisciplinary linkages Suggesting alternative ways to improve programmes and research processes  Tailoring for diverse groups and settings  Adapting tools for delivery with different groups in different places, settings and situations Being flexible in design and delivery Working and learning cross culturally Recognizing gender differences and tailoring for different participant needs  Developing and using evidence  Using participatory evaluation methods Using cultural frameworks to develop and build an evidence base Recognizing limitations (and often harm) associated with use of western frameworks and research processes Acknowledging and valuing different sources of evidence including Indigenous knowledge Building on past programme experiences and lessons  Our model identifies and describes four inter-related implementation processes and three conditions influencing the implementation of health promotion tools. For local planning purposes, the model provides a basis for organizations to justify resource allocation and investment in strategies for creating conditions for culturally responsive health promotion. Efforts to create these conditions, often known as ‘the invisible work’ of health promotion (Hawe et al., 1997), may easily be overlooked in the rush to produce more tools or other materials (e.g. posters, pamphlets, flipcharts) as ‘products’ of health promotion funding. This study supports the value of investing time and resources in the social relations and processes related to what people actually do when they are implementing tools, particularly the processes by which tools are made workable to support and enhance rather than replace local efforts. Barriers associated with implementing ‘top down’ tools might be avoided by increasing awareness of these conditions and processes locally and centrally. The model could also be used by practitioners and tool developers in designing and evaluating health promotion tool dissemination and implementation interventions. Given the dearth of impact evaluation studies in Indigenous health promotion (McCalman et al., 2014; O'Donoghue et al., 2014), there is little evidence for whether tools work to improve Indigenous health promotion let alone for the conditions required for implementation. The components of this model provide a framework for planning, documenting and assessing implementation to help determine health promotion tool effectiveness. Funding bodies could also use the model to design funding applications or forms, requiring agencies to report on what strategies they will use to create (or mitigate against) conditions for culturally responsive health promotion (i.e. the presence of change agents; commitment to reciprocity and organizational governance and resourcing). The potential of the theoretical model for implementing mainstream health promotion tools for the benefit of Indigenous Australians requires careful consideration. Under these circumstances, tool implementation would need to ensure the necessary conditions for facilitating empowerment through culturally responsive health promotion. CONCLUSIONS In summary, the model of health promotion tool implementation suggests that rather than producing more health promotion tools, future efforts should focus on strengthening implementation processes and supporting the conditions necessary for facilitating empowerment through culturally responsive health promotion. For policy and decision makers, the key components of the model provide a useful blue print to inform funding and reporting on Indigenous health promotion investment. For practitioners and researchers, the model offers a framework for systematically documenting and assessing implementation processes and the conditions influencing implementation. Given the diversity of tools included in this study and their implementation environments, the model is likely to be transferable for implementing other Australian Indigenous health promotion tools in Indigenous comprehensive PHC services. However, our model would be enhanced through comparative implementation studies of other Australian Indigenous and global Indigenous health promotion tools. While constructing the final theoretical implementation model, an Indigenous co-author reminded us: A risk is for us researchers to overstate the value of new tools. If the tools and process are not taken up by community organisations, either because they are culturally inappropriate or capacity is not developed to use them, then this is not empowering and is potentially damaging because it risks misrepresenting Indigenous health promotion. This in turn can be another barrier to communities implementing programs they need to maintain and strengthen cultural, social, physical wellbeing - another barrier to self-determination. (J. Doyle, 2015, personal communication, 19 February). AUTHORS' CONTRIBUTIONS N.P. took a primary role in the paper’s conception and design, acquisition of data, and analysis and interpretation of data using grounded theory methods. J.M.C. and C.A. contributed to acquisition of data, and analysis and interpretation of data using grounded theory methods. R.B. advised on and contributed to interpretation of data using grounded theory methods and revised the manuscript for cultural appropriateness and intellectual content. L.O.D. contributed to data acquisition and interpretation of data and revised the manuscript for cultural appropriateness and intellectual content. K.R. and J.D. contributed to acquisition and interpretation of data and revised manuscript. K.T. advised on the paper’s conception and critically revised the manuscript for intellectual rigour. All authors read and approved the final manuscript. FUNDING This work was funded by and has been produced as part of the activities of The Lowitja Institute, Australia’s National Institute for Aboriginal and Torres Strait Islander Health Research, which incorporates the Cooperative Research Centre for Aboriginal and Torres Strait Islander Health (CRCATSIH). The Cooperative Research Centres program is an Australian Government Initiative. CONFLICT OF INTEREST None declared. REFERENCES Anderson I., Thomas D. 2006. Aboriginal Health is Improving. Aboriginal and Islander Health Worker Journal , 30, 5. Anderson P. 2014. 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Scoping Study of Health Promotion Tools for Aboriginal and Torres Strait Islander People: A Report Prepared for the Lowitja Institute. Melbourne: The Lowitja Institute. World Health Organisation. 1978. Declaration of Alma Ata on Primary Health Care . USSR, Alma-Ata: World Health Organisation. World Health Organization. 1986. The Ottawa Charter for Health Promotion. Geneva, Switzerland: WHO. http://www.who.int/healthpromotion/conferences/previous/ottawa/en/index.html (last accessed 28 June 2016). © The Author 2016. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Health Promotion International Oxford University Press

Implementing health promotion tools in Australian Indigenous primary health care

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Abstract

Abstract Background In Australia, significant resources have been invested in producing health promotion best practice guidelines, frameworks and tools (herein referred to as health promotion tools) as a strategy to improve Indigenous health promotion programmes. Yet, there has been very little rigorous implementation research about whether or how health promotion tools are implemented. This paper theorizes the complex processes of health promotion tool implementation in Indigenous comprehensive primary healthcare services. Methods Data were derived from published and grey literature about the development and the implementation of four Indigenous health promotion tools. Tools were theoretically sampled to account for the key implementation types described in the literature. Data were analysed using the grounded-theory methods of coding and constant comparison with construct a theoretical implementation model. Results An Indigenous Health Promotion Tool Implementation Model was developed. Implementation is a social process, whereby researchers, practitioners and community members collectively interacted in creating culturally responsive health promotion to the common purpose of facilitating empowerment. The implementation of health promotion tools was influenced by the presence of change agents; a commitment to reciprocity and organizational governance and resourcing. Conclusion The Indigenous Health Promotion Tool Implementation Model assists in explaining how health promotion tools are implemented and the conditions that influence these actions. Rather than simply developing more health promotion tools, our study suggests that continuous investment in developing conditions that support empowering implementation processes are required to maximize the beneficial impacts and effectiveness of health promotion tools. Indigenous, Aboriginal, health promotion, empowerment, transfer, spread, implementation, primary health care INTRODUCTION Closing the significant gaps in health and wellbeing equity between Indigenous and non-Indigenous populations is one of the greatest global challenges. Despite Australia’s world-class health system, the life expectancy of Aboriginal and Torres Strait Islander peoples (respectfully referred to hereafter as Indigenous Australians) is estimated to be ∼10.6 years lower for Indigenous males and 9.5 years lower for Indigenous females than that for non-Indigenous males and females, respectively (Australian Institute of Health and Welfare, 2015). There is a growing body of evidence, however, that with sustained and concerted efforts, health promotion can reduce the greater Indigenous burden of preventable illnesses and conditions compared with other Australians (Anderson and Thomas, 2006; Demaio et al., 2012). Health promotion, defined as the process of enabling people to increase control over the determinants of health and thereby improve their health (World Health Organization, 1986), can contribute to health equity and social justice through empowering responses. Empowerment involves both processes and outcomes that generate change at multiple levels—individual, organizational and community—strengthening the capacity for collective action to influence social situations positively (Wallerstein, 1992). It entails the ability of people to assert and claim their legitimate rights in any given situation, and their capacity to accept and willingly discharge responsibilities towards themselves, others and society (Tsey, 2009). Pat Anderson, the Chairperson of Australia’s Indigenous Health Research Centre, the Lowitja Institute, recently argued that empowerment or ‘the control factor’ is central to closing the gap in health and wellbeing equity between Indigenous and other Australians. She stated ‘any policy or programme aimed at reducing the disadvantage of our communities must from its conception through to its implementation and beyond, ask itself how it will increase the ability of Aboriginal people, families and communities to take control over their own lives’ (Anderson, 2014). The desire to close the health and life expectancy gap between Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians has led government and non-government organizations to invest considerably in the development of health promotion tools (McCalman et al., 2014). Indeed, health promotion tools, including those developed specifically for Indigenous Australian populations, are widely available, as evidenced by the more than 1900 health promotion tools identified in a recent scoping study (Wise et al., 2012). McCalman et al. (McCalman et al., 2014) define health promotion tools as structured (often step-by-step) guidelines, instruments, packages and resources designed for improving the planning, implementation and evaluation of Indigenous health promotion programmes or improving existing ones. These health promotion tools differ from other health promotion and education materials, such as posters, pamphlets and flipcharts, which are designed and used primarily to explain a health issue or procedure and written in non-technical language for patients or the broader public. Despite wide production and availability of health promotion tools, however, there has been very little rigorous research about how health promotion tools are implemented (McCalman et al., 2014). Importantly, health promotion tools will have limited scope to achieve their intended impact if they are poorly implemented. Implementation refers to the processes by which an innovation is assimilated into use within an organization (Damschroder et al., 2009). Previous studies have found Ovretveit’s (Ovretveit, 2011) typology of implementation useful for describing and identifying different approaches in Indigenous health programme implementation (McCalman, 2013a, McCalman et al., 2012). Ovretveit (Ovretveit, 2011) argues that implementation can occur through (i) a hierarchical, centrally driven and controlled process; (ii) a more decentralized and participatory adaptive approach supported by experts or (iii) an informal and largely uncontrolled grass roots process whereby organizations define their problems and search for ‘packaged solutions’ which they can adapt to address local needs. To optimize the potential of health promotion tools to reduce Indigenous disadvantage, it is important to develop an understanding of how tools are implemented and how they could be more effectively implemented. Study background and aims The work presented in this paper resulted from a collaboration between researchers based in three Australian universities (located in Brisbane, Melbourne, Cairns and Darwin campuses), as part of a health promotion initiative funded by Australia’s National Institute for Aboriginal and Torres Strait Islander Health Research, the Lowitja Institute. In 2011, the Lowitja Institute held a collaborative workshop for researchers, policy makers, practitioners and community members to establish a project aimed at improving knowledge and understanding about the uptake and implementation of tools to strengthen health promotion in Indigenous comprehensive primary health care (PHC) services. The Lowitja Institute describes Indigenous comprehensive PHC services as services that take a holistic view of health, delivering health care in accordance with principles of PHC as embodied in the Declaration of Alma-Ata (World Health Organisation, 1978). To strengthen the evidence-base for health promotion in Indigenous comprehensive PHC services, the Lowitja Institute adopted a phased approach. Stage 1 was a scoping study of Indigenous health promotion tools (Wise et al., 2012). In Stage 2, the current author team systematically examined the characteristics, implementation and effects of 74 Indigenous health promotion tools. We found a lack of attention to how tools were implemented in practice (McCalman et al., 2014). From previous work, we were also aware of the lack of theoretical conceptualizations about how health innovations are implemented in the Australian Indigenous context, with most being programme specific (McCalman et al., 2012). To address this gap in the literature, and to build on our Stage 2 findings, this paper reports on the development of an Indigenous health promotion tool implementation model. The key study objective was to theorize the processes including the conditions, strategies and outcomes through which health promotion tools are implemented in Indigenous comprehensive PHC services. METHODS Study design To explain and theorize implementation, we examined how tool facilitators go about implementing health promotion tools, why tools are being implemented and with what outcomes. Constructivist grounded theory was chosen as the most suitable method because of the intent to build an applied theoretical model from the practical experience and knowledge of those directly involved in the phenomena under study; and because of its appropriateness for Australian Indigenous settings (Bainbridge et al., 2013; Birks and Mills, 2011; Charmaz, 2006). Secondary data were used to theorise implementation processes and construct the model. Secondary data in grounded theory is defined as ‘any data collected in the past for purposes not originally related to the current study’ (Bainbridge et al., 2013). The advantage of using such data collected from earlier studies is that it saves time, money and other resources (Birks and Mills, 2011). In particular, in the context of Australian Indigenous health research, the use of secondary data avoids unnecessary data collection from Indigenous people who have been traditionally over-researched (Bainbridge et al., 2015; Whiteside et al., 2012). Sampling health promotion tools and data sources Researchers, practitioners, policy makers and community members attending the collaborative workshop organized by the Lowitja Institute (described above) identified health promotion tools from the results of the Stage 1 scoping study (Wise et al., 2012). Two criteria guided the selection process: (i) the tools must be designed specifically to strengthen programmes aimed at improving Indigenous Australian or other Indigenous population’s health and wellbeing; and (ii) implemented in Indigenous comprehensive PHC services. This resulted in the identification of three health promotion tools: (i) the Continuous Quality Improvement tools in health promotion (HPCQI); (ii) the Family Wellbeing (FWB) community education empowerment programme; (iii) the tool for monitoring the ecological approach of health promotion programmes [the Ecological Coding Procedure (ECP) and its associated data collection instrument as used in the Creating Healthy Environments (CHE) and other health promotion evaluation projects in Victoria]. A fourth tool, the Community Health Action Pack (CHAP), was subsequently included in the study after our data analysis revealed a theoretical gap in the initial sample of tools (described below). Data sources for the current study were identified by requesting nominations of grey and published reports from people involved in the development, implementation and/or evaluation of the health promotion tools and by reviewing publicly available documentation about the tools. In grounded theory, data collected via such a selective sampling process has been referred to as tentative theoretical ‘jumping-off point’ from which to begin theory development (Thompson, 1999). Through discussion and consensus among the current author team, nine reports and publications were selected (Doyle et al., 2013; Johnston et al., 2013; McCalman, 2013a, 2013b; O'Donoghue et al., 2014; Percival, 2014; Reilly et al., 2007, 2008, 2011). These data sources were chosen on the basis that they provided the richest and most relevant information about the development and implementation of the health promotion tools and in turn, were the data sources that would yield the strongest empirical concepts for constructing a theoretical model (Draucker et al., 2007). A brief description of the four health promotion tools, implementation type, the organizations where tools were implemented and data sources used for this study are provided in Table 1. Table 1: Health promotion tools: descriptions, aims, implementation settings and study data sources Tool/implementation type  Tool description and aims  Where implemented  Data sources  Family Wellbeing Program (FWB)—Facilitated evolutiona  A generic personal and community empowerment programme that is consistent with healing approaches for Indigenous peoples. FWB provides the tools for participants to create their own outcomes, which leads to a broad range of effects in participants’ health, employment, education, parenting, relationships or whatever is relevant for the person at that time. FWB was developed by Indigenous people, for Indigenous people.  Diverse implementing organizations (including government, non-government, private and academic entities) geographically located in 56 sites across Australia  Peer-reviewed paper (McCalman, 2013b) A PhD thesis based on in-depth interviews with Aboriginal and non-Aboriginal research respondents who had been active in transferring the programme across Indigenous communities and healthcare settings (McCalman, 2013a).  Ecological Coding Procedure (ECP)—Facilitated evolutiona  A systematic tool to describe and capture the degree of integration of the ecological perspective in health promotion programmes. Originally developed for application to mainstream health promotion programmes in Canada and modified to monitor health promotion programme implementation in a Mohawk community. The tool has also been tailored for use in an Indigenous community as part of the CHE project in Victoria, Australia.  Three community based organizations located in the semi-urban Goulburn-Murray region of northern Victoria, Australia.  Peer-reviewed papers (Reilly et al., 2007, 2008, 2011; Doyle et al. 2013; Johnston et al., 2013).  Health Promotion Continuous Quality Improvement (HPCQI)—Participatory adaptationb  A structured and facilitated approach to assist primary health care centres strengthen their health centre systems and improve development and delivery of health promotion activities that meet the needs of their local population. CQI tools enable the systematic collection of information to determine the extent to which delivery of health promotion and health centre systems align with best practice. When repeated, changes in practice and systems and explanations for those changes, can be monitored over time. HP CQI was adapted from existing CQI tools and processes in response to demand from primary health care services  Four Indigenous primary health care services in the Northern Territory, Australia.  Peer-reviewed paper (O'Donoghue et al., 2014). A PhD thesis based on assessments of practice records and semi-structure group interviews with Indigenous and non-Indigenous staff of four Northern Territory primary health care services involved in the development and implementation of the CQI tools (Percival, 2014).  Community Health Action Pack (CHAP)—Hierarchical controlc  CHAP was developed as part of the Local community campaigns to promote better Aboriginal and Torres Strait Islander health programme, a measure under the Australian Government's Indigenous chronic disease package (ICDP). The CHAP includes templates, examples, checklists and tips to help with planning a health promotion project. The CHAP is designed to be flexible so that communities and organizations can use it to suit their own needs, in particular the CHAP was used to support newly established ICDP Healthy Lifestyle workforce. Organizations receiving funding for Healthy Lifestyle Workers were provided copies of the CHAP.  24 primary health care services across Australia, spanning rural, remote and regional areas.  A government report based on semi-structured interviews with Indigenous Healthy Lifestyle workers (predominately Aboriginal Tobacco Action Workers, Healthy Lifestyle Workers and Regional Tobacco Coordinators) clinicians and health centre managers working in Indigenous and mainstream primary health care services across Australia who were involved in using the CHAP to design and deliver healthy lifestyle programmes with their local community (Bailie et al., 2013).  Tool/implementation type  Tool description and aims  Where implemented  Data sources  Family Wellbeing Program (FWB)—Facilitated evolutiona  A generic personal and community empowerment programme that is consistent with healing approaches for Indigenous peoples. FWB provides the tools for participants to create their own outcomes, which leads to a broad range of effects in participants’ health, employment, education, parenting, relationships or whatever is relevant for the person at that time. FWB was developed by Indigenous people, for Indigenous people.  Diverse implementing organizations (including government, non-government, private and academic entities) geographically located in 56 sites across Australia  Peer-reviewed paper (McCalman, 2013b) A PhD thesis based on in-depth interviews with Aboriginal and non-Aboriginal research respondents who had been active in transferring the programme across Indigenous communities and healthcare settings (McCalman, 2013a).  Ecological Coding Procedure (ECP)—Facilitated evolutiona  A systematic tool to describe and capture the degree of integration of the ecological perspective in health promotion programmes. Originally developed for application to mainstream health promotion programmes in Canada and modified to monitor health promotion programme implementation in a Mohawk community. The tool has also been tailored for use in an Indigenous community as part of the CHE project in Victoria, Australia.  Three community based organizations located in the semi-urban Goulburn-Murray region of northern Victoria, Australia.  Peer-reviewed papers (Reilly et al., 2007, 2008, 2011; Doyle et al. 2013; Johnston et al., 2013).  Health Promotion Continuous Quality Improvement (HPCQI)—Participatory adaptationb  A structured and facilitated approach to assist primary health care centres strengthen their health centre systems and improve development and delivery of health promotion activities that meet the needs of their local population. CQI tools enable the systematic collection of information to determine the extent to which delivery of health promotion and health centre systems align with best practice. When repeated, changes in practice and systems and explanations for those changes, can be monitored over time. HP CQI was adapted from existing CQI tools and processes in response to demand from primary health care services  Four Indigenous primary health care services in the Northern Territory, Australia.  Peer-reviewed paper (O'Donoghue et al., 2014). A PhD thesis based on assessments of practice records and semi-structure group interviews with Indigenous and non-Indigenous staff of four Northern Territory primary health care services involved in the development and implementation of the CQI tools (Percival, 2014).  Community Health Action Pack (CHAP)—Hierarchical controlc  CHAP was developed as part of the Local community campaigns to promote better Aboriginal and Torres Strait Islander health programme, a measure under the Australian Government's Indigenous chronic disease package (ICDP). The CHAP includes templates, examples, checklists and tips to help with planning a health promotion project. The CHAP is designed to be flexible so that communities and organizations can use it to suit their own needs, in particular the CHAP was used to support newly established ICDP Healthy Lifestyle workforce. Organizations receiving funding for Healthy Lifestyle Workers were provided copies of the CHAP.  24 primary health care services across Australia, spanning rural, remote and regional areas.  A government report based on semi-structured interviews with Indigenous Healthy Lifestyle workers (predominately Aboriginal Tobacco Action Workers, Healthy Lifestyle Workers and Regional Tobacco Coordinators) clinicians and health centre managers working in Indigenous and mainstream primary health care services across Australia who were involved in using the CHAP to design and deliver healthy lifestyle programmes with their local community (Bailie et al., 2013).  a Facilitated evolution (or grass roots approach) focuses on assisting communities identify local priorities and locate practices and models to suit their needs, rather than adapting a model that has been imposed. b Participatory adaptation relies on the replication of models across locations, allowing for decentralized decision-making by providing local support for communities to make local adaptations. c Hierarchical control (often conceptualized as ‘push’ or ‘top down’ approach) occurs when a practice or model effective in one location is identified and then replicated at other locations, often with directive detailed plans (Ovretveit, 2011). Data analysis The selected data sources were imported into NVIVO 10. Initial readings of the data sources provided the author team with an overview of each tool and its purpose, the implementation processes and contextual factors. We collated key or main points from each data source by coding text line-by-line. The codes arising out of each data source were constantly compared against codes, firstly from data sources for the same tool, and then data sources from other tools to identify theoretical constructs (Graffigna, 2009). The constant comparison method was applied to group codes into higher-order concepts and repeated until higher-order categories and their relationships were identified (Kelle, 2007). As theory development progressed, a gap in the initial sample of tools was identified. Consistent with grounded theory methods, theoretical sampling was used whereby initially sampling was purposive, with later sampling directed by concepts arising from the evolving theory (Birks and Mills, 2011). Only two of the three types of implementation approaches (participatory adaptation and facilitated evolution) were included; a tool that reflected hierarchical control or a ‘top down’ implementation approach was not represented (Ovretveit, 2011). Ovretveit (Ovretveit, 2011) argues that ‘top down’ implementation ‘is the traditional approach used by ministries of health or large non-government organizations, which delegate and direct lower regional levels and facilities under their control to carry out specific changes’ (p. 242). To address this gap, we sought examples of government-funded, developed and/or centrally driven Australian Indigenous health promotion tools. Two impact evaluations of government implemented tools (Hearn et al., 2011; Hunter et al., 2004) were identified in our previous literature review (McCalman et al., 2014). However, we were also aware of a more recent evaluation of a large scale nation-wide initiative, The Indigenous Chronic Disease Package (ICDP), to which two of the authors of this paper had contributed (Bailie et al., 2013). The ICDP included an unprecedented investment in Indigenous Australian health promotion, including the development of the CHAP. The CHAP was designed to support planning of health promotion programmes with Indigenous communities (Department of Health and Ageing, 2011). The CHAP was included as the fourth health promotion tool as it met the inclusion criteria and filled the theoretical gap in tool sampling. The author team met face-to-face to construct the final theoretical implementation model. With sensitivity to the possibility that the analysis may be Western-centric (Johnston et al., 2013), Indigenous researchers and practitioners on our author team ensured the analytical interpretations and findings reflected Indigenous perspectives and experiences of implementing and/or evaluating the health promotion tools in Indigenous comprehensive PHC services. The constant comparison method of examining and comparing the concepts continued until we were satisfied that the higher-order categories and their relationships could be modelled in such a way that explained the great majority of the data and until the central concern (core category) of those involved in implementing health promotion tools and the core process that facilitated that concern were identified (Birks and Mills, 2011). The central concern is the category considered the ‘main theme’ or ‘main concern or problem’ for the study participants (Glaser, 1978). Through an iterative analysis process, and consistent with the intent of health promotion, we determined that the tool facilitators’ central concern for implementing health promotion tools was ‘facilitating empowerment’. The resultant model and explanation of why and how health promotion tools were implemented is described and presented below. RESULTS A model of Indigenous Health Promotion Tool Implementation was constructed (see Figure 1). The model incorporates the common purpose for which health promotion tool implementation occurred (facilitating empowerment; inner circle); the conditions that influenced tool implementation (reciprocity, change agents and governance and resourcing; outer circle); processes that represented the interrelated and overlapping practices of implementation (engaging and relating, strengthening capacity, tailoring for diverse groups and settings, and developing and using evidence; intermediate ring); and benefits arising from health promotion tool implementation (lower centre). The components of the model and explanation of the processes that frame the implementation of health promotion tools in comprehensive Indigenous PHC services are presented below. Theoretical terms are italicized. Figure 1: View largeDownload slide Indigenous Health Promotion Tool Implementation Model—facilitating empowerment through culturally responsive health promotion. Figure 1: View largeDownload slide Indigenous Health Promotion Tool Implementation Model—facilitating empowerment through culturally responsive health promotion. Summary of health promotion tool implementation model The research found that implementing health promotion tools was a social process involving researchers, practitioners and community members (herein referred to as tool facilitators) working collectively, within a specific context, over time. The implementation process reflected patterns of dynamic and contingent interactions between: tool facilitators that interact in doing the work of implementing health promotion tools; the health promotion tool itself; and the organizations within which the tool facilitators and tools come together. The work of implementing health promotion tools, that is what tool facilitators do and how, manifested as four processes (engaging and relating, developing and using evidence, tailoring for diverse groups, programmes and settings, strengthening capacity). These four processes are dynamic and interrelated and together reflected a core implementation process of creating culturally responsive health promotion. Three conditions influenced what tool facilitators do and how they work. First, tool implementation required the presence and continuous investment by people who act as change agents. Change agents were individuals with the mind-set and skills set for promoting and supporting individual, organization and community health promotion. The second condition was a commitment to and practice of reciprocity. Reciprocity described the set of values and principles that guide the actions and decisions of change agents and reflected the mutual respect and valuing of the benefits of diversity, dialogue and shared learning. Third, was organizational governance and resourcing; a structural condition that reflects the resourcing, willingness and capability of Indigenous comprehensive PHC services and the associated workforce to do the work of implementing tools. Under favourable conditions, facilitating empowerment through culturally responsive health promotion resulted in benefits including participant satisfaction and control; workforce recruitment and capacity; organizational resources, systems and partnerships; and programme sustainability and spread. Why implement health promotion tools? Facilitating empowerment was the primary reason for implementing health promotion tools in Indigenous comprehensive PHC services. This driving concern was pertinent despite differences in the tool types, focus, theoretical and evidential underpinnings. For tool facilitators, empowerment was about using strategies that generated change at multiple levels—individual, organizational and community—to assist Indigenous people take collective action, control and responsibility in any given situation. Facilitating empowerment was important to tool facilitators because it reflected their desire to act as facilitators or enablers, rather than doers, in supporting Indigenous people, families and communities to understand and use their strengths as the basis for change. This was reflected in a comment by a non-Indigenous co-author during construction of the final theoretical model, explaining the role of the tool facilitator in implementing FWB: Irrespective of whatever is happening, as researchers, how can we develop relationships with people, organisations? How can we find, through those relationships, what people are trying to achieve? Is there a way research can enable and add value, enhance that process? So whether it’s men’s groups, whether it’s women’s groups, whether it’s people trying to establish a community controlled organisation or have the footy club or whatever, is there a role for research to support that? (K. Tsey, 2014, personal Communication, 24 April) How are health promotion tools implemented? The process of health promotion tool implementation occurred through culturally responsive health promotion. Health promotion that was culturally responsive occurred when tool facilitators acknowledged Indigenous knowledge, local culture and social systems as an essential part of the complex implementation environment. Creating culturally responsive health promotion was imperative for ensuring a good ‘fit’ between the health promotion tool and the implementation context. Culturally responsive health promotion was more than culturally tailoring health promotion tools. Critical to working effectively in cross cultural situations was valuing and engaging with traditional expressions of Indigenous culture and modes of knowledge dissemination. Importantly, this meant accounting for and reflecting on the influence of historical and contemporary policies and programmes on the health system itself, including health promotion, given it has been experienced by many Indigenous Australians as an extension of colonization/agent of the state (McPhail-Bell et al., 2016). In practice, culturally responsive health promotion manifested as four inter-related and overlapping processes of: engaging and relating; strengthening capacity; tailoring for diversity in programmes, groups and settings; and developing and using evidence. Engaging and relating The first process, engaging and relating, was about developing and maintaining relationships with individuals, their organizations, and the broader policy and community environments. The way tool facilitators went about implementing health promotion tools was the foundation on which relationships and trust were established. Issues of participation, collaboration and community-direction were considered paramount. By building and elaborating upon existing processes and incorporating capacity building strategies, tool facilitators took a strengths-based approach towards creating social environments and relationships that would support action to progress Indigenous health promotion priorities. This was how tool facilitators went about engaging and relating to empower the community to take control of the implementation process. Reilly et al. (Reilly et al., 2007) explained of ECP that the process ‘…hinges on a power shift: outside professionals no longer attempt to control the development process solely on their own terms’ (p. 40). The process of engaging and relating fostered a safe space for tool implementation and thus was reciprocity in practice. An Aboriginal FWB tool facilitator, reflected: ‘It gives that two-way understanding, that’s what Family Wellbeing does….We’re all at this level of understanding…it gets back to that safe space. It allows that two-way understanding to take place because it’s creating that safe place for dialogue to occur.’ (McCalman, 2013b, p. 5) Similarly, creating a safe space for a quality improvement dialogue between researchers and local practitioners facilitated the implementation of HPCQI tools. The two-way dialogue between researchers and local staff assisted local PHC teams to make sense of their data, understand the extent to which health promotion aligned with best practice, and to identify priorities and plan for improvements (Percival, 2014). Strengthening capacity The second process, strengthening capacity for Indigenous health promotion, was also necessary in the work of implementing health promotion tools. Strengthening capacity was a process for, and an outcome of, implementing health promotion tools. Actions for strengthening capacity were focused at the individual worker and organization levels by improving individual practitioner access to materials and resources; improving individual practitioner knowledge and skills in health promotion; and strengthening and modifying the environment (organizational, community and policy levels) to support Indigenous health promotion. For example, training, mentoring and providing support for Indigenous researchers, workers and community members was a common capacity building strategy, as was facilitating group dialogue. An ECP Aboriginal tool facilitator reflected on the process of strengthening capacity of community members: …we brought together some focus groups to look at nutrition and what it meant to our whole community in the area in which we work. We looked at a range of people from a young age to an older age. We talked about things like, ‘what in the food chain do you understand? What does this meant to you? (Reilly et al., 2008, p. 173) Participatory evaluation methods, featuring a collaborative process between tool facilitators and local teams in creating a shared awareness and understanding of the tool and its purpose, assisted the development of local capacity for implementing the centrally produced CHAP. Early indications of implementation success were shared at both the local and policy levels and, in turn, developed the capacity of individuals and organizations to more independently access resources and address their own health promotion priorities in the future (Bailie et al., 2013). Tailoring for diversity of programmes, groups and settings The third strategy was tailoring for diversity of programmes, groups and settings. Originally developed from different theoretical and evidential underpinnings, each tool required some adaptation and modification to better align with their implementation context. Tool facilitators used iterative processes to tailor for the diversity of programmes, groups and settings. For example, initially developed for application to mainstream health promotion programmes in Canada (Levesque et al., 2005), the ECP had to be modified to better represent and capture Indigenous Australian peoples’ relationships to each other and the world (Rowley et al., 2015). Its use was not intended to change the nature or implementation of Indigenous health promotion, but to allow a more accurate description of community-led programmes. This experience and its collaborative application in retrospective analyses (Johnston et al., 2013) led to the need to modify the theoretical basis of the ECP (Rowley et al., 2015). CQI tools have been most extensively used in the clinical health care context and required modifications in their development and implementation to suit Indigenous health promotion. Once the HPCQI tools were developed, implementation was tailored to cater for the needs of different levels of practitioner and organization health promotion capacity at each Indigenous PHC service. A similar process of tailoring for local circumstances occurred for the nation-wide implementation of the CHAP (Bailie et al., 2013). FWB was also adapted for various settings, issues and target groups, and has been variously delivered as a community development and employment, training and capacity development, health promotion, empowerment research and school education programme (McCalman, 2013b). Developing and using evidence The fourth process, developing and using evidence, entailed first, acknowledging and valuing different sources of evidence and, second, using culturally appropriate means for gathering and synthesizing these different sources of evidence. The source of evidence was considered particularly important because it affected the credibility of the evidence, improved users’ confidence in the utility of the tool and their willingness to apply it to improve Indigenous health promotion. Tools were highly valued by Indigenous people when they were developed and delivered or facilitated by Indigenous researchers. An Aboriginal FWB tool facilitator reflected: Our mob when we hear that it’s been developed by our own people, that’s the only reason why sometimes I think they come along to it. So I think that’s the most critical thing. And that it works of course, but you know, people don’t know that it’s going to work until they’ve done it. But to get them there is, you know, that’s just so so important; that it is developed by Aboriginal people. (McCalman, 2013b, p5) Tool facilitators used participatory methods to gather and synthesize the evidence derived from different sources. For example, an audit and feedback process was used for implementing the HPCQI tools (O'Donoghue et al., 2014). This process enabled practitioners to collect information about local health promotion activities in a standardized and systematic way and compare this with best practice. Recognizing divergent interpretations of evidence from Western and Indigenous perspectives was important for implementing health promotion tools. Johnston et al. (Johnston et al., 2013) found of ECP implementation, that, while non-Indigenous researchers perceived walking groups as an intervention targeting individuals, Aboriginal researchers perceived walking groups as an inherently interpersonal and public activity that fostered closer relationships between individuals, families, the organizations they dealt with and the communities in which they were located. These differences in interpretations highlight the need for integrating local Indigenous knowledge with Western research and practice expertise in the design, implementation and evaluation of health promotion programmes. Developing and using evidence was also seen as a way of gaining credibility for Indigenous health promotion ‘through a white system as well’ (McCalman, 2013a). For example, the ECP tool provided a method for recording, analysing and reporting local health promotion activities in an ecological framework. An ecological framework acknowledges social and emotional determinants of health, including those found to be of specific importance to Indigenous communities, including history, relationship with mainstream, connectedness and a sense of community and individual control (Johnston et al., 2013). The documentation of the nature and aims of Indigenous led health promotion was used to influence funders and decision makers. Conditions influencing implementation Although there was huge diversity in Indigenous comprehensive PHC services, for example, in their geographical location, organizational and associated workforce health promotion capacity, there were common conditions that enabled and/or inhibited what tool facilitators do and how they work, and thus influenced health promotion tool implementation. These three conditions were: the presence of change agents, a commitment to reciprocity; and supportive organizational governance and resourcing. Maintaining relationships and sustaining implementation of health promotion tools required long term commitment of change agents. Trust between researchers, practitioners and community members as tool facilitators had been established over many years, often as a result of dialogue and collaboration on previous projects. This continued investment by change agents was important for realizing the benefits of tool implementation by improving local health promotion activities. For example, having a co-facilitator from the local health centre was important for securing local ownership and implementation of the HPCQI tools. Furthermore, the intensity and sustained engagement of the research team as co-facilitators was found to be a significant factor in closing the evidence-practice gap in the health promotion capacity of PHC practitioners and Indigenous PHC service systems (Percival, 2014). Reciprocity was considered an instructional condition that edifies culturally responsive health promotion; providing guidance for how tools were implemented in each setting and situation. Reciprocity was the set of values and principles that guided the actions and decisions of change agents and reflected the mutual respect and valuing of the benefits of diversity, dialogue and shared learning. Across settings and situations, people brought different perspectives, understandings and assumptions about the value, meaning and benefits of implementing health promotion tools. Reciprocity was necessary for recognizing and valuing these multiple perspectives and for guiding actions and decisions for how tools were implemented in each setting and situation - an important approach for improving the health of Aboriginal and Torres Strait Islander people through research (National Health and Medical Research Council, 2010). In ECP implementation, a commitment to reciprocity was formalized through a memorandum of understanding between participating organizations and the community (Reilly et al., 2007, p. 41). Good organizational governance and adequate resourcing was also an important condition that influenced tool implementation. The funding made available for implementing the CHAP provided for organizational infrastructure and recruiting, and enabled individualized training and support for the establishment of a new Healthy Lifestyle Worker workforce (Bailie et al., 2013). Bailie et al.(Bailie et al., 2013, p. 68) explained how this resourcing helped to validate the role of the healthy lifestyle worker within the broader function of the PHC organization: These structures and processes fostered more support for individual workers and validated their role within the broader function of the organisation. At an organisational level, this required a clear vision of how the measures, including the new workforce, should work and a strategic approach to training, learning and development to achieve a workforce capable of designing and delivering tobacco and healthy lifestyle initiatives based on best available evidence. The limited, short-term and insecure nature of health promotion funding, however, created a barrier to implementation by disrupting employment of workers and making it more difficult for people to stay engaged with activities. For example, in implementing ECP, Doyle et al. note the difficulty for an Indigenous sporting club to obtain funding despite it being a major site through which cultural identity, healthy lifestyles, employment, education and other aspects of health promotion and community development are strengthened (Doyle et al., 2013). Ongoing implementation of FWB programme has also been constrained by a lack of funding and resourcing. ….to try and get that level of sustainability is quite difficult for a program of the sort we’re talking about, very difficult really. If you look across the public sector programs…which are non-mainstream, to survive 10 years is quite a challenge, when you’re looking at….at least three governments in a period of time like that. (McCalman, 2013b, p. 7) Benefits of tool implementation Health promotion tool implementation resulted in benefits at individual, workforce and organization levels. At the individual level, people noted they felt satisfied and in control of implementation processes. For example, a PHC practitioner commented on their satisfaction with the CHAP implementation processes saying that it was the first time in a government programme they’d been asked ‘how we were going and what does this mean for us’ and ‘not do a tick box’ (Bailie et al., 2013). Furthermore, (Reilly et al., 2007, p. 173) noted of community member’s involvement in implementing ECP: so they put those things on the table themselves and we never even stated that to them; they did it for themselves. So they did want to know about it, but they wanted to take control and do it themselves The way tool facilitators went about implementing health promotion tools also resulted in strengthened health promotion workforce and organizational capacity. For example, the combination of local and external facilitator knowledge in HPCQI implementation was important for interpreting results and exploring relationships between local practice and what was recognized as best practice. By improving health centre information systems, health promotion evidence was developed through better documentation of local activities that were previously ‘invisible’. This process also translated to improvements in practitioner knowledge and understanding of health promotion and strengthened organizational capacity for health promotion (O'Donoghue et al., 2014). Similarly, the resourcing through the ICDP created favourable conditions for implementing the CHAP: ICDP not only increased capacity of organisations by increasing the number of positions but through developing the knowledge and skills of a new workforce, and through improving health promotion capacity among the existing workforce (Bailie et al., 2013, p.69) In turn, programme sustainability and spread was observed in the implementation of ECP as a benefit from strengthened health promotion capacity. The implementation strategies were participatory in that it was conceived by the participants themselves, and has been embraced enthusiastically by participants, who are now lobbying on their own behalf for the continuation of the group and the provision of appropriate resources (Reilly et al., 2007, p. 44) POTENTIAL LIMITATIONS Challenges arose for our analysis from the use of secondary data sources. The opportunity to interrogate aspects of the tools’ implementation was limited by the descriptions provided in the available reports and publications. Secondary data also limited the flexibility necessary for true theoretical sampling (Birks and Mills, 2011). We considered that given the lack of descriptions about implementation processes reported in the published and grey literature (McCalman et al., 2012, 2014), the inclusion of additional secondary data about health promotion tools was unlikely to provide us with information that would add substantially to our implementation model. Instead, we drew on our involvement in the development, implementation and/or evaluation of the four tools (as well as in the primary data collection and analysis) coupled with our in-depth knowledge of Indigenous health promotion in comprehensive PHC services more broadly, to validate assumptions and propositions in data analysis and construction of the theoretical model. DISCUSSION Drawing from studies of four health promotion tools, we conceptualise implementation as a social process, whereby researchers, practitioners and community members interact in creating culturally responsive health promotion with the common purpose of facilitating empowerment. The impetus of facilitating empowerment reiterates the key function of health promotion, defined as the process of enabling people to increase control over the determinants of health (World Health Organization, 1986) and is consistent with health promotion core values and ideals (Berry et al., 2014; Tsey, 2009). Importantly, this study expands our understanding of how to implement health promotion in the context of Indigenous health. The lack of health promotion success in Indigenous communities has been criticized because it fails to account for the importance of local cultures and continues to have minimal emphasis on capacity building, community empowerment and local ownership (Demaio et al., 2012). Furthermore, efforts to address these criticisms have emphasized strengthening individual practitioner capabilities with less focus on strategies to address health service and broader system factors (Freeman et al., 2014). Indigenous Australians have been long arguing for control over their own affairs and for greater investment in strategies that not only strengthen their own capacity for collective action but also that of government, service systems, organizations and the workforce to generate change and influence social situations positively (New South Wales Health Department, 2002; Tsey et al., 2010). Our implementation model acknowledges that empowerment is not a straight forward concept but a multi-level construct that encompasses strategies for enabling individual, organizational and community-level change. Paradoxically, health promotion tool implementation does not reflect the seemingly linear ‘structured, often step-by-step’ instruction as implied by definition (McCalman et al., 2014). The means of making health promotion tools freely available through websites or sending copies through the mail, as has been identified as the most common strategy for disseminating health promotion tools (McCalman et al., 2014) may not be the most effective way for attaining maximum benefits of health promotion tools. Our study suggests that rather than simply developing more health promotion tools, continuous investment in change agents, a commitment to reciprocity, and adequate and sustainable funding and resourcing, are required to support implementation and maximize the beneficial impacts and cost effectiveness of health promotion tools. A number of studies have demonstrated that the implementation approach or methods for facilitating the delivery of Indigenous health services or programmes affects success (Bailie et al., 2013; Gardner et al., 2010; Hunter et al., 2004). Furthermore, other international models and theories of implementation highlight that implementation success is influenced by facilitation methods or implementation processes (Damschroder et al., 2009; Kitson et al., 2008). Yet, the motivations of implementation are lacking attention or are not given explicit consideration. Similarly, in the health promotion field, values and principles, including equity, empowerment and participation, are central yet intrinsic concepts that are not often made explicit or questioned in every day practice (Berry et al., 2014). Working to change or improve people’s social realities is value laden. Clearly, to optimize the utility of Indigenous health promotion tools, and other Indigenous health innovations, requires thoughtful analysis of not only what we do, but how and why. Implications for health promotion policy and practice The concept of empowerment is central to the work of health promoters, yet a major challenge facing the health promotion field is understanding what this means and how it shapes everyday policy and practice (Berry et al., 2014; Tsey, 2009). Table 2 outlines examples of how tool facilitators can go about implementing health promotion tools to enable Indigenous people to increase control over and to improve their health and wellbeing. Derived from our theoretical model, and identified by the author team, we offer these as practical examples of culturally responsive health promotion for potential use by other tool facilitators. Table 2: Processes of culturally responsive health promotion to facilitate empowerment Culturally responsive health promotion  Strategies of culturally responsive health promotion  Engaging and relating  Listening and responding to input and feedback Making connections with the community by involving key members of the community and recruiting local people Feeding back to community Disseminating and sharing ideas through structured communication channels such as committees and decision making groups and informal channels such as word-of-mouth Linking with partner organizations  Strengthening capacity  Training, mentoring and supporting individuals and teams and aligning with workforce competencies Accessing resources by making available online Influencing and/or obtaining funding support Enhancing cultural competencies by promoting/developing multidisciplinary linkages Suggesting alternative ways to improve programmes and research processes  Tailoring for diverse groups and settings  Adapting tools for delivery with different groups in different places, settings and situations Being flexible in design and delivery Working and learning cross culturally Recognizing gender differences and tailoring for different participant needs  Developing and using evidence  Using participatory evaluation methods Using cultural frameworks to develop and build an evidence base Recognizing limitations (and often harm) associated with use of western frameworks and research processes Acknowledging and valuing different sources of evidence including Indigenous knowledge Building on past programme experiences and lessons  Culturally responsive health promotion  Strategies of culturally responsive health promotion  Engaging and relating  Listening and responding to input and feedback Making connections with the community by involving key members of the community and recruiting local people Feeding back to community Disseminating and sharing ideas through structured communication channels such as committees and decision making groups and informal channels such as word-of-mouth Linking with partner organizations  Strengthening capacity  Training, mentoring and supporting individuals and teams and aligning with workforce competencies Accessing resources by making available online Influencing and/or obtaining funding support Enhancing cultural competencies by promoting/developing multidisciplinary linkages Suggesting alternative ways to improve programmes and research processes  Tailoring for diverse groups and settings  Adapting tools for delivery with different groups in different places, settings and situations Being flexible in design and delivery Working and learning cross culturally Recognizing gender differences and tailoring for different participant needs  Developing and using evidence  Using participatory evaluation methods Using cultural frameworks to develop and build an evidence base Recognizing limitations (and often harm) associated with use of western frameworks and research processes Acknowledging and valuing different sources of evidence including Indigenous knowledge Building on past programme experiences and lessons  Our model identifies and describes four inter-related implementation processes and three conditions influencing the implementation of health promotion tools. For local planning purposes, the model provides a basis for organizations to justify resource allocation and investment in strategies for creating conditions for culturally responsive health promotion. Efforts to create these conditions, often known as ‘the invisible work’ of health promotion (Hawe et al., 1997), may easily be overlooked in the rush to produce more tools or other materials (e.g. posters, pamphlets, flipcharts) as ‘products’ of health promotion funding. This study supports the value of investing time and resources in the social relations and processes related to what people actually do when they are implementing tools, particularly the processes by which tools are made workable to support and enhance rather than replace local efforts. Barriers associated with implementing ‘top down’ tools might be avoided by increasing awareness of these conditions and processes locally and centrally. The model could also be used by practitioners and tool developers in designing and evaluating health promotion tool dissemination and implementation interventions. Given the dearth of impact evaluation studies in Indigenous health promotion (McCalman et al., 2014; O'Donoghue et al., 2014), there is little evidence for whether tools work to improve Indigenous health promotion let alone for the conditions required for implementation. The components of this model provide a framework for planning, documenting and assessing implementation to help determine health promotion tool effectiveness. Funding bodies could also use the model to design funding applications or forms, requiring agencies to report on what strategies they will use to create (or mitigate against) conditions for culturally responsive health promotion (i.e. the presence of change agents; commitment to reciprocity and organizational governance and resourcing). The potential of the theoretical model for implementing mainstream health promotion tools for the benefit of Indigenous Australians requires careful consideration. Under these circumstances, tool implementation would need to ensure the necessary conditions for facilitating empowerment through culturally responsive health promotion. CONCLUSIONS In summary, the model of health promotion tool implementation suggests that rather than producing more health promotion tools, future efforts should focus on strengthening implementation processes and supporting the conditions necessary for facilitating empowerment through culturally responsive health promotion. For policy and decision makers, the key components of the model provide a useful blue print to inform funding and reporting on Indigenous health promotion investment. For practitioners and researchers, the model offers a framework for systematically documenting and assessing implementation processes and the conditions influencing implementation. Given the diversity of tools included in this study and their implementation environments, the model is likely to be transferable for implementing other Australian Indigenous health promotion tools in Indigenous comprehensive PHC services. However, our model would be enhanced through comparative implementation studies of other Australian Indigenous and global Indigenous health promotion tools. While constructing the final theoretical implementation model, an Indigenous co-author reminded us: A risk is for us researchers to overstate the value of new tools. If the tools and process are not taken up by community organisations, either because they are culturally inappropriate or capacity is not developed to use them, then this is not empowering and is potentially damaging because it risks misrepresenting Indigenous health promotion. This in turn can be another barrier to communities implementing programs they need to maintain and strengthen cultural, social, physical wellbeing - another barrier to self-determination. (J. Doyle, 2015, personal communication, 19 February). AUTHORS' CONTRIBUTIONS N.P. took a primary role in the paper’s conception and design, acquisition of data, and analysis and interpretation of data using grounded theory methods. J.M.C. and C.A. contributed to acquisition of data, and analysis and interpretation of data using grounded theory methods. R.B. advised on and contributed to interpretation of data using grounded theory methods and revised the manuscript for cultural appropriateness and intellectual content. L.O.D. contributed to data acquisition and interpretation of data and revised the manuscript for cultural appropriateness and intellectual content. K.R. and J.D. contributed to acquisition and interpretation of data and revised manuscript. K.T. advised on the paper’s conception and critically revised the manuscript for intellectual rigour. All authors read and approved the final manuscript. FUNDING This work was funded by and has been produced as part of the activities of The Lowitja Institute, Australia’s National Institute for Aboriginal and Torres Strait Islander Health Research, which incorporates the Cooperative Research Centre for Aboriginal and Torres Strait Islander Health (CRCATSIH). The Cooperative Research Centres program is an Australian Government Initiative. CONFLICT OF INTEREST None declared. REFERENCES Anderson I., Thomas D. 2006. Aboriginal Health is Improving. Aboriginal and Islander Health Worker Journal , 30, 5. Anderson P. 2014. 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Health Promotion InternationalOxford University Press

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