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Table 2 Study Synthesis using the He Pikinga Wairoa Elements

From: Implementation effectiveness of health interventions for indigenous communities: a systematic review

Study Community engagement Cultural centeredness Systems thinking Integrated knowledge translation
Observational Studies
 Benyshek et al. 2013 The intervention was delivered by Native lifestyle coaches and this facilitated connection with participants. The intervention was developed using community-based participatory research (CBPR) methods although specific details on the process are not clear. Researchers adapted the programme to tailor to urban American Indians. The community was informed and engagement was limited to adapting the intervention; problem definition and solution identification by the community not apparent. The interview process allowed for feedback loops. The target of change was at the individual level. The systems considered were those that already existed. Limited evidence of systems thinking. There was no direct discussion with end users other than using CPBR to adapt the intervention.
 Christopher et al. 2008 A CBRP approach was used. Strong community involvement at every phase of development and implementation with evidence of shared decision making. Lay health advisors were used to deliver the intervention and were selected by the community. Both the researcher and community leaders had equal say in the development of the intervention with the community identifying the problem. Intervention was delivered within the structure of the community and provided additional services. Research reflexivity clearly noted in the article. There was demonstration of good understanding and respecting the community systems. The project altered their intervention based on the feedback received. Messages targeted individuals directly and community indirectly. Almost every aspect of the intervention was co-created with community members including some community organisations. Engagement with other end users was not directly discussed.
 Coppell et al. 2009; The project had a participatory approach with the community involved in all project phases. A memorandum of understanding (MOU) was established between the researchers and communities before the first attempt of developing a Māori-led diabetes intervention. Community health workers were a key engagement approach with participants. Researchers completed surveys to assess the severity of diabetes and confirm the communities concerns. The project developed a vision that was shared and owned by the community. The intervention involved multiple structures and provided resources to the community. Researcher reflexivity engaged though the partnership. The whole community was included. By working with all members of community the intervention impacted the individual, the community and the local stores and businesses, allowing creating opportunities for a positive change at every level. Feedback loops were highlighted as a crucial aspect for this project. The intervention engaged with stores,schools and local employers to support the intervention structurally (e.g., create school policies consistent with the intervention). The intervention was driven by the community and community leaders. Thus, there was a high-level of engagement with stakeholders and end users.
 Kaholokula et al. 2014 The project was part of a CBPR partnership called the PILI ‘Ohana Project. This project was a partnership between researchers with five community organisations. Community members and community organisations were integrated in all phases of the research. The intervention was adapted with community participation and the community helped identify the problem and solution. Researcher reflexivity reflected in an ongoing partnership. Community peer educators helped to make cultural connection with participants. Equal partnership of community and academic investigators involved from the beginning of the study to integrate the best combination of community and scientific knowledge. Partnership involved multiple aspects of the Native Hawaiian health system. Only individual level of analysis for the intervention. The partnership includes relationship with the Native health system, community health centres, and grassroots organisations. The CBPR approach offered the benefit of building capacity within the difficult to reach communities in this study. The level of knowledge translation beyond study period is not described.
 Kakekagumick et al., 2013 Research project reflects a long-time partnership involving multiple projects guided by community engagement. Research project included shared decision making and communication in all elements of the research over a 22-year period. The need for the interventions was identified by the community and the various interventions reflect the wishes of the community. Interventions provided new resources and changed existing structures. Reflexivity is noted through reciprocal learning and capacity building. A number of projects addressed multiple causes of the health issue, accessibility, costs, environment, social support and lack of adequate facilities. Relationships were forged in each phase with community groups, schools, community health services, and sports teams addressing multiple systems levels. Vast array of feedback was received through these relationships that shaped the design, implementation and outcome of the overall study. The project is a partnership of the Sandy Lake First Nation and researchers. The project has been active for 22 years demonstrating that it is a sustainable model that has transformed the community over time. End users highly engaged in all phases of the research.
 Reilly et al. 2011 The project was overseen by a steering committee of senior community and university representatives. They were bound by a MOU between participating organisations that stipulated rules for community ownership and storage of data. The project was implemented by local health workers. Trust between the university researchers and the Koori community had been established over many years as a result of collaboration on previous projects. Initial consultation was conducted with the community around the health and health determinants of the community. The academic researchers worked closely with community researchers who coordinated the development and delivery of the program. Academic researchers took a supportive role, offering advice and suggestions but only participating directly in planning and design when requested. The project created a health promotion programme aligned to an ecological approach. It targeted changes in the nutrition environment with the thought that individual behaviour would change (although not directly assessed in the study). Further, multiple aspects of the health promotion and food supply system were considered. Community representatives on the steering community were members of Aboriginal partner organisations. Specific activities involved engagement with end users from these organisations. Intervention strategies were devised in response to each aims following discussions between participating organisations and reflections on previous findings and experiences of participants.
 Shah et al. 2015 The lead researcher had a prior relationship with the community although there is no clear partnership identified. Tribal leaders and health programs were consulted. Community health representatives recruited participants and delivered the intervention. The health issue was identified through surveys with community members. Participants were involved in the development of the intervention through focus groups and a cultural specific education interventions. The researchers made the majority of the final design and implementation decisions. The intervention aimed to deliver healthcare that emphasized greater autonomy/self-management. The intervention targeted individual behaviour and no other levels considered. Limited evidence of systems thinking. While tribal leaders and health programs were consulted at the beginning, there is no evidence of ongoing engagement with these end users.
Randomised Control Trials
 Brimblecombe et al. 2017 This intervention utilised grocery stores to implement price discounts for healthy food options and provide nutrition education. The community engagement involved finding communities and stores to take part in the intervention. There was an agreement with the non-profit associations affiliated with the stores and store boards. The researchers talked to store boards to share study protocol and sign an agreement to follow the protocol and help recruit research assistants. That nature of the problem is well defined although the communities did not select the problem directly or suggest the solution. There is general research evidence suggesting Aboriginal communities wanted this type of intervention. The intervention did provide resources (i.e., discounts) to community members to purchase healthy food. The research focusses on the larger food system as a potential manner to improving healthy food consumption. The overall project includes evaluation of overall food buying patterns for stores and individual behaviour although this study only includes the larger buying patterns. The study recognises the larger systemic issues and relationships that shape individual consumption patterns although the actual study implementation does not directly include engagement with all of these issues and relationships. Knowledge translation efforts with end users was minimal. The store boards were consulted although only for approval of the study. This is a top-down approach where the researchers have identified an issue and have developed an intervention they feel is appropriate. No discussion of policy or practice change beyond the study period is identified.
 Canuto et al. 2012 The project was guided by an advisory committee made up of local Indigenous women. Some of members were representatives from the collaborating organization and provided input into the interpretation of qualitative data. Participants were recruited based on the intervention requirements. The committee provided advice on feasibility of the project’s procedures and assessments ensuring that all aspects of the project were culturally appropriate. There did not appear to be any direct input on defining the problem although there was input on the solution. Reflexivity not apparent. The intervention considered a variety of potential factors for programme success. It was focused only on individual level outcomes. Systems levels, relationships and perspectives were not considered at great depth other than barriers for participation. This intervention development included initial consultation with two community organisations. The focus was more on making sure the intervention was culturally appropriate rather than how to engage in knowledge translation.
 Ho et al. 2008 Community engagement was achieved through local organisations helping to facilitate implementation of the project. Decision making and communication was largely directed by the researchers although communities had input that led to adaption of the intervention in the specific locales. Semi-structured interviews were done with multiple community members to assess acceptability, feasibility and sustainability of the intervention. Thus, some community voice was included to help make the intervention culturally appropriate. There was no direct evidence that the community was able to select the problem to address or how to address it. This intervention was implemented into three different systems: school, food store and larger community. It planned to change the systems and provide a healthier outlook for both communities. Multiple stakeholders were included and different perspectives gathered. Feedback loops were supplied during feasibility testing. The majority of the knowledge integrated at the beginning of the project was from the researchers and project team. Community health workers and researchers expressed a desire to sustain the intervention if supplied with materials so there was some potential knowledge translation activities.
 Kaholokula et al. 2012 The project was part of a CBPR partnership called the PILI ‘Ohana Project. This project is a partnership between researchers with five community organisations (health centres, health care systems, and grassroots organisations). Compromises were made by each to ensure the best intervention design for the participants providing evidence of shared decision making and communication. The partnership provided equal insights about the importance of focusing on diabetes. Feedback on the intervention was gathered in three activities; focus groups, informant interviews, and pilot testing. A steering committee was established and oversaw the translation of a previous diabetes intervention to ensure cultural appropriateness. Delivered by community health advocates to enhance cultural connection. Reflexivity evidenced through ongoing partnership. The study acknowledged the important role community organisations play in designing and implementing health interventions in Indigenous communities. The partnership involved multiple aspects of the Native Hawaiian health system. Only individual level of analysis for the intervention. Systems where altered for the translation of the intervention, though it is unclear if it is an ongoing change, or if it was only for the period of the intervention. Changes to the intervention were made based off of community organisation advice and these are key end users in the Native Hawaiian health system. No direct discussion of sustainability of the intervention.
 Karanja et al. 2010 Researchers worked with various community representatives to craft and implement the intervention including community health workers. Three communities received the intervention and were able to adapt and tailor intervention plans to fit their communities. There was some sharing of decision making and communication through these intervention plans. Community members and agency representatives were able to help to craft messages and policies. Structural changes were sought in health and business settings. Whether the community had a say in the definition of problem and choice of health issue is not clear despite clear involvement during the intervention development and implementation. Reflexivity is not discussed. The intervention targeted community and family-level behaviour. The community level include a variety of elements and perspectives including media messages and policy changes in businesses and health settings. There was opportunity for feedback to adapt intervention plans. Numerous end users were engaged in the implementation of the intervention. They provided responsibility for implementation of aspects of the community intervention. Sustainability or intention to sustain is not discussed.
 Kolahdooz et al. 2014 The intervention development process was a community participatory approach through the use of community workshops and qualitative and quantitative formative research. Shared decision making was enacted through the workshops in deciding the appropriate intervention and intervention messages. No mention is made of community researchers or research partners. The formative research process provided community voice for identifying the problem. The community workshops ensured there was community voice for the solution. Culturally appropriate research processes and interventions were utilized. Reflexivity is not directly discussed. The intervention process considered multiple perspectives and stakeholders (from grocery stores, community sites and health organisations). Effort was made towards changing the systems that usually promote unhealthy food and eating habits. Relationships among the organisations and larger system were noted in developing a healthy food environment. Intervention targeted community, organisation and individual levels. Community voice was integrated from the beginning and knowledge translation efforts included participation from community members, local leaders, government health workers and grocery shop staff. There was no mention whether these efforts led to sustainability of the intervention.
 Mendham et al. 2015 The intervention was designed and implemented by the project team with minimal engagement from the community. Community organisations were utilised for recruitment of participants. The authors noted development of interventions by the community increased ownership yet never described any engagement efforts. The intervention was developed to fit communal values by focusing on group-based and sports activities. There is no evidence suggesting the community was involved in defining the problem or identifying the solution. No reflexivity or structural changes are noted. The intervention only targeted individual behaviour although within a group context. The study did not consider larger systems or environments. Limited systems thinking is evidenced. Members of an Aboriginal community organisations were consulted although there is not any direct efforts at knowledge translation. The focus of the intervention was on individual behaviour with limited engagement with end users.
 Simmons et al. 2008 The engagement aspects included a Māori Steering Group and Māori community health workers. There was not much consultation with the community on the design and implementation of the intervention. CHWs were employed to deliver the intervention though they had no input into the content. The CHWs helped improve the implementation of the intervention. The community had limited input into defining the problem or solution. The intervention was provided to the CHWs. CHWs helped to adapt research processes to better fit cultural values of the community. CHWs served as personal trainers to participants. There was reflexivity post study although limited evidence during the implementation process. CHWs had social networks that gave them a unique ability to interact with the participants. The CHWs enhanced the experience for the participant based on their knowledge of the programme and the system. The implementation team did not realise the complex systems elements that shaped CHW work or the social networks of the community that affected implementation of the project (i.e., research model did not fit service expectations of the community). The research team worked with Māori providers and other end users within the health system to implement the project. However, they were not partners in the project and there is no direct evidence of knowledge translation efforts.
 Sinclair et al. 2013 The study was part of an existing CBPR partnership called the PILI ‘Ohana Project. A steering committee assisted in the planning and implementation of this study. Focus groups provided community engagement/perspectives for the design with peer educators used for implementation. Shared decision making and communication reflected throughout the research phases. The curriculum for this study was adapted for the community using input from the steering committee and community focus group; this ensured the curriculum had culturally relevant knowledge and activities. Peer educators and steering committee members also contributed local and cultural knowledge by reviewing written materials and making suggestions for activities. Reflexivity evidenced through an ongoing partnership. The partnership involved multiple aspects of the Native Hawaiian health system. Only individual level of analysis for the intervention. Key relationships were built in the community with the project leaders and the local community organisations. The partnership includes relationship with the Native health system, community health centres, and grassroots organisations. Thus end users were engaged throughout the process. The level of knowledge translation beyond study period is not clear.
 Tomayko et al. 2016 Project used CPBR throughout the research process. Community members and tribal leaders were integrated throughout the design and planning of the intervention. Members from health, education, child welfare, and tribal government bodies of the three initial participating communities met with researchers at a collaboration meeting to discuss results from a previous study with the community and possible interventions. On-going research with the community assisted in building relationships and trust within the communities and study idea came from this previous research so reflects community voice in problem definition and solution. Community organisations were able to adapt the intervention to their communities. All materials and research processes were culturally appropriate (e.g., no control group, but rather having an alternative intervention group and having home mentors be community members). The intervention focussed on family-level positing the best way to change individual behaviour was to incorporate the family. Other aspects of the community were not directly considered. Home mentors were used to facilitate programme delivery. Other systems thinking aspects were not addressed. The intervention was developed with key end users including wellness staff and tribal leaders. They offered input to the intervention and the fact that all participants needed to have an intervention. Continued efforts by community to continue obesity prevention efforts included obtaining additional funding.
Qualitative Studies
 English et al. 2008 A CBPR process was used throughout the intervention. Tribal community, academic institution, and intertribal organisations joined together to share information and resources to collectively design a community-based intervention. Many preliminary activities were conducted to build relationships with the community. The preliminary activities allowed the project team to gain a better understanding of the issues among the community. Education courses were held to advance community empowerment. Focus groups were held for participants to discuss the barriers to receiving health care. Community voice was evidenced through and the partnership used reflexive dialogue. Resources were brought to community members to facilitate screening. The projected was guided by the socioecological framework. Systems networking allowed structural changes to happen within bigger organisations. Hospital staff agreed to setting specific days aside for the participants which encouraged their participation in the project. Community health workers were members of the community themselves and worked to inform participants and recruit for the project. Tribal leaders and community organisations were included in the participatory process. Efforts sought to develop policy change. Authors concluded that the intervention was sustained by the community.
 Sushames et al. 2017 There is no clear initial consultation with the participants before the intervention was designed and implemented. It was noted there was a participatory process with support by local Indigenous mentors and a local Aboriginal health organisation. Despite this notation, there is no clear indication of shared decision making or partnership between the researchers and the community. The intervention included interviews although they were only conducted post intervention. They were also conducted by a non-Indigenous researcher, who had previous established relationships with the participants. The analysis was conducted by the research team. No clear evidence of its processes in designing the intervention and inclusion of community voice beyond the use of local Indigenous mentors. The mentors helped provide insights on cultural ideologies. The study focused on enablers and barriers to participation which included elements at various levels in the system. These helped illustrate the larger community systems and relationships among people and cultural constructs. The study helped to illustrate why the intervention was not well attended despite having positive impacts. There was limited engagement with end users with only a local organisation consulted primarily for recruiting participants. It was noted that this intervention did not have sustainable outcomes for the communities.
 Townsend et al. 2015 The study was part of an existing CBPR partnership called the PILI ‘Ohana Project. An existing steering committee assisted in the planning and implementation of this study. This study involved genetic testing and engagement with the steering committee was paramount for the implementation of the study. Biospecimens were required for this study which caused some concern for the community. The steering committee met several times to determine an appropriate process. The intervention had semi-structured support groups to address any new or pending concerns from the participants. They also held an informal meeting for community participants for reassurance. Thus, there was good community voice for approval of the project. Reflexivity is evidence by ongoing dialogue about the project. The project acknowledged the larger history about genetic testing in Indigenous communities and sought ways to address these issues. A follow-up was conducted in a community setting and the committee took on board the feedback from the participants to create a newsletter presenting the general findings. Focus groups were also held with eight participants to discuss their thoughts on the intervention. These enabled feedback loops to be included. End users from the community organisation where the study took place was engaged in the process. This engagement and trust building allowed the study to happen. Further data collection/genetic testing is thus an option.
 Tumiel-Behalter et al. 2011 This study was held in four different communities (one Indigenous). Each community initially received the same core intervention although researchers and community partners quickly learnt that they needed to be adapted to each community. Researchers reached out to community organisations within the areas to identify a community partner to collaboratively adapt and implement the programme. Community partners and participants were asked to provide feedback to the overall project team to improve the program. Various formats such as focus groups, conversational interviews and surveys were implemented throughout the process on an ongoing basis to continually improve the program. The feedback assisted not only the overall project, it also allowed the community partners to create the changes. Community voice was acknowledged in the adaption of the core programme. Project staff sought to integrate the intervention into the local community infrastructure. Activities targeted individual and community change. There was acknowledgement of social determinants of health and key social issues (e.g., drugs, violence, and unemployment). End users in each community were consulted with the goal to initiate the programme with funds, staff and resources, and to gradually transfer ownership and leadership to the community partner as the programme progressed. The input from the end users helped to make the programme sustainable in most of the communities, including the Indigenous community.