441230
2012
GHP19210.1177/1757975912441230Demaio et al.Global Health Promotion
Commentary Appropriate health promotion for Australian Aboriginal and Torres Strait Islander communities: crucial for closing the gap Alessandro Demaio1, Marlene Drysdale2 and Maximilian de Courten1
Abstract: Health promotion for Australian Aboriginal and Torres Strait Islander communities and their people has generally had limited efficacy and poor sustainability. It has largely failed to recognise and appreciate the importance of local cultures and continues to have minimal emphasis on capacity building, community empowerment and local ownership. Culturally Appropriate Health Promotion is a framework of principles developed in 2008 with the World Health Organization and the Global Alliance for Health Promotion. It serves as a guide for community-focused health promotion practice to be built on and shaped by the respect for understanding and utilisation of local knowledge and culture. Culturally Appropriate Health Promotion is not about targeting, intervening or responding. Rather, it encourages health programme planners and policymakers to have a greater understanding, respect, a sense of empowerment and collaboration with communities, and their sociocultural environment to improve health. This commentary aims to examine and apply the eight principles of Culturally Appropriate Health Promotion to the Australian Aboriginal and Torres Strait Islander context. It proposes a widespread adoption of the framework for a more respectful, collaborative, locally suitable and therefore appropriate approach to Australian Aboriginal and Torres Strait Islander health promotion. (Global Health Promotion, 2012; 19(2): 58–62) Keywords: Advocacy, collaboration, partnership, community, equity and social justice, health promotion, health determinants, policy, programme planning and management
Introduction Aboriginal and Torres Strait Islander Australians (Aboriginals) are known to suffer the poorest health of any group within Australia and, arguably, within the developed world’s First Nations people (1). Taylor wrote: It is not credible to suggest that one of the wealthiest nations of the world cannot solve a health crisis affecting less than 3% of its citizens (2). This chronic crisis requires new approaches and strategies which are built in partnership with Australian Aboriginal communities aimed at consciously Closing the Gap (3) in Aboriginal ill health.
The current Aboriginal health promotion campaigns including Closing the Gap (3) follow the Ottawa Charter principles to advocate, enable and mediate. They highlight that strategies and programmes should be adapted to the local communities (4). The authors of this paper go much further and call for health promotion practice to be built on and shaped by the respect for and understanding of local communities, their culture as well as their knowledge. Culturally Appropriate Health Promotion (CAHP) provides an empirical framework for this paradigm shift (5). CAHP is not simply about targeting, intervening or responding. Rather, it strives for the understanding, empowerment and respect of communities and their sociocultural environments. It aims to sustainably influence health
1. School of Global Health, University of Copenhagen, Copenhagen, Denmark. Correspondence to: Alexandre Demaio, [email protected] 2. Indigenous Health Committee and Indigenous Health Unit, Monash University, Monash, Australia.
Global Health Promotion 1757-9759; Vol 19(2): 58 –62; 441230 Copyright © The Author(s) 2012, Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1757975912441230 http://ghp.sagepub.com Downloaded from ped.sagepub.com at TEXAS A&M UNIV TEXARKANA on August 20, 2015
A. Demaio et al.
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Table 1. Culturally appropriate health promotion principles 1. Community involvement, consultation and empowerment 2. Socioculturally tailored health promotion techniques 3. Community evaluation and feedback in real time 4. The utilisation of local communication techniques 5. Maximisation of both the spoken word and the local tongue 6. Sustainable health development and community health autonomy 7. Holistic in nature, addressing the needs of the whole person 8. Spirituality and social connectedness as health determinants
and its determinates through the appreciation of local wisdom and in collaboration with local people. Health promotion for Aboriginal communities has to date had generally limited efficacy and poor sustainability (6). Largely failing to recognise and appreciate the importance of local cultures, it continues to place minimal emphasis on capacity building or community strengthening and ownership (7). Moving forward, health promotion within Aboriginal communities needs to celebrate the diversity of cultures within this population rather than seeing it as a hurdle. Culture and its facets should be regarded as important social determinants and possible catalysts for health. These cultural determinants include socioeconomic circumstances, numerous languages and dialects, geographic location, and importantly the consequences of colonisation (8). This commentary examines and applies the eight principles of Culturally Appropriate Health Promotion to the Australian Aboriginal context. This framework was developed by the lead author of this paper in 2008 under the direction of the World Health Organization and the NGO Alliance for Health Promotion (5).
Applying CAHP principles to Australian Aboriginal health Community involvement, consultation and empowerment There is a need to recognise and acknowledge the diversity of Aboriginal communities and their individual cultures, rather than assuming cultural homogeneity. Communities must be involved in every stage of health programme development, implementation and evaluation and play a meaningful, integral role. Com munities should be involved from the programme
outset. Achieving this requires health promotion to engage with local communities, organisations and individuals at an early stage. This can be achieved through, but not limited to, community consultation and committees, focus groups, surveys, interviews and local advisory groups. Health promotion planners need to recognise the value of existing community assets and build upon them sustainably. These assets may include aspects of the culture itself, which could lead to catalysing health improvements, or encourage key community members to assist in building community knowledge, motivation or mobilisation.
Socioculturally tailored health promotion techniques The chosen health promotion methodology should reflect the local community, their needs and their cultural values, rather than those of the research team or health promotion organisation. Health promotion must be community-focused, based around culturally appropriate messages and should reflect the priorities of the community. It is also crucial that health promotion programmes recognise there is much to learn from local communities themselves. This knowledge should be reflected in programmes and act as a framework for their methodological development. For example, recognition of traditional healers, their knowledge and their holistic approach to healing could provide a valuable approach for health promotion strategies.
Community evaluation and feedback in real time Part of the CAHP ideology is a capacity for commu nity evaluation, providing feedback of programmes IUHPE – Global Health Promotion Vol. 19, No. 2 2012
Downloaded from ped.sagepub.com at TEXAS A&M UNIV TEXARKANA on August 20, 2015
Commentary
60
on current community opinions, efficacy and interpretation of programmes. Community meetings and participation in advisory boards are crucial to engaging communities and ensuring local control and ownership. This creates an opportunity for timely programme improvement, allowing health promotion coordinators to adapt and reflect the local community’s needs. It should be recognised that communities work within their own timeframes and not necessarily those of the health promotion programme. Therefore, programme managers need to allocate adequate time to involve the community rather than have a rush in rush out approach.
The utilisation of local communication techniques Communication and subsequent interpretation of information are key processes in health promotion. As local communication techniques vary greatly between communities, beyond the spoken language, programme communication techniques must reflect the individual community demographics, culture and values. The use of symbols and area-specific artwork that engage local artists may result in more effective and appropriate communication with communities (9). Recognising and understanding the complex communication pathways in Aboriginal communities is important. An example would be the importance of gender and gender roles, which may result in a young woman seeking female-only healthcare staff. Such a request should be respected and viewed in its wider cultural frame. Another example is the importance of valuing and engaging community Elders who are leaders, gatekeepers and protectors for their community. It is only through mapping and understanding these local communication pathways, that effective health promotion strategies can be developed.
Maximisation of both the spoken word and the local tongue CAHP aims to minimise the reliance of health promotion programmes on written text. In addition, it utilises local language and, where possible, regional dialects and their individual phrases, slangs and idioms. Health promotion should understand, celebrate and utilise local language and
its cultural framing, avoiding complex or jargonistic text, which is exclusive and disempowering to communities.
Sustainable health development and community health autonomy Opportunities for up-skilling local researchers, allowing replication or adaptation of health promotion programmes beyond their final endpoints, should be sought. When engaging communities, programmes that build local capacity allow communities to have control over future programmes and their own health. This includes recognising community assets early, valuing them, strengthening them and building upon them. Health promotion planners should have the ultimate aim of programme self-sustainability, community autonomy and health ownership. Programme sustainability and Aboriginal ownership are essential to improving indigenous health long-term.
Holistic in nature, addressing the needs of the whole person It is recognised that health status is largely determined by the complex interplay of sociocultural, economic and educational determinants. Therefore health promotion must aim to address and alleviate problems of poverty, illiteracy and illness concurrently. A holistic approach to health is even more crucial in an Aboriginal setting where programmes too often focus on a biomedical, vertical and fragmented strategy. Health promotion programmes must engage the whole community and focus on their needs. Social determinants of health including housing, education, unemployment and poverty need to be co-addressed through and within health programmes. It should be recognised that health promotion can provide a powerful vehicle for empowering communities to overcome these determinants and improve their own health.
Spirituality and social connectedness as health determinants Spirituality and a sense of social connection have a great influence on health and wellbeing at an individual level (10). This is amplified when applied
IUHPE – Global Health Promotion Vol. 19, No. 2 2012
Downloaded from ped.sagepub.com at TEXAS A&M UNIV TEXARKANA on August 20, 2015
A. Demaio et al.
to a population and can have major downstream effects in regards to nutrition, exercise and stress. Health promotion programmes should recognise the importance of and strengthening community spirituality and social connectedness as key determinants of Aboriginal health (11). The connection of Aboriginal people to their land, place and space needs to be understood and seen as a basis for health, social cohesion and collective wellbeing.
Applying the principles: Australian quit smoking campaign The Quit Smoking Campaign aimed to reduce smoking prevalence in all Australian communities. Whilst being widely successful, it had little impact on Aboriginal smoking rates where the prevalence continues to be more than double that of the general population (12). One reason for this failure was that it did not appropriately engage with Aboriginal communities and their culture (13). A recent audit of tobacco control programmes showed that whilst many agencies ‘adapted’ materials specifically for a perceived homogenous Aboriginal audience, none of them used local languages or dialects (13). Such blanket approach tailoring has not sought to understand communities, their knowledge or their traditions. These traditions can in part explain the high smoking rates in these communities, including tobacco playing a role in cultural ceremonies and important cultural beliefs that act as direct barriers to nicotine replacement use (14). Applying the principles of CAHP, communities should have been involved in campaign design from the beginning (Principles 1 and 3). Had they been involved, smaller-scale, more appropriate programmes may have been developed. Better reflecting the diverse nature of Aboriginal communities, these microcampaigns would have been more flexible to the local needs, cultures and communication methods of their people (Principle 2). Including and empowering communities, local leaders and their formal and informal healthcare services are key elements to promoting health in Aboriginal communities (15) (Principles 1 and 6). Greater community involvement and ownership leads to opportunities for capacity building within a community. Health programme planners must work with communities to build their own responses to smoking, rather than imposing a national campaign. This would afford skills,
61
knowledge and the tools for more meaningful and sustainable campaign outcomes (Principle 6). How information is communicated is also important (Principles 2 and 5). Campaigns that recognise and reflect the particular community-level communication pathways and hierarchy would be better able to combat smoking (Principle 4). In Aboriginal communities, this could see traditional Elders engaged as ambassadors of health promotion (16). Programmes that include a focus on older, prominent community members not only aim to reduce ill health in a highrisk group but may also initiate widespread declines in smoking behaviour through important rolemodelling (17). The Forgotten Smoker, a report from the Australian Medical Association, found that in contrast to non-Aboriginals, many Aboriginal communities find it harder to connect with and relate to famous health role models because they are not perceived as having to face the everyday stresses of an ordinary life. This report also explained that health promotion for an Aboriginal audience, particularly Aboriginal youth, should emphasise family themes and use story lines in order to enhance their reach and penetration (9) (Principle 2). Tom Calma, former Australian Race and Social Justice Commissioner, pragmatically states ‘we need a different message for indigenous people’. The above example of current anti-smoking campaigns supports this view and highlights the need for a more intelligent, respectful and thoughtful approach to Aboriginal health promotion.
Conclusion This commentary examined and applied the principles of Culturally Appropriate Health Promotion to the Australian Aboriginal and Torres Strait Islander context. Its authors propose the adoption of this framework to achieve more respectful, collaborative and locally acceptable approaches to Aboriginal health promotion. Health promotion strategies should value Australian Aboriginal communities as partners who must be intimately and extensively involved in all stages of the health promotion process. Furthermore, health promoters should seek to understand and apply the knowledge and expertise of communities, to all levels of their practice. Ignoring communities, particularly at the early stages of programme development and IUHPE – Global Health Promotion Vol. 19, No. 2 2012
Downloaded from ped.sagepub.com at TEXAS A&M UNIV TEXARKANA on August 20, 2015
Commentary
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implementation can lead to a programme–community disconnect. This will be reflected in the programme’s ability to engage with the local community and ultimately deliver on its aims for better health. Governments, policymakers and the health promo tion planners should strive for Culturally Appropriate Health Promotion. That is, considering target populations as partners and health interventions as partnerships. These communities should be empowered through health promotion activities that aim to share knowledge rather than impart it and to develop sustainable, community-owned, locally driven and culturally grounded health improvements. References 1. Demaio A. Local Wisdom and Health Promotion; Barrier or Catalyst. Geneva, Switzerland: World Health Organization; 2008. 2. Taylor K, Guerin P. Health care and Indigenous Australians: Cultural Safety in Practice. Australia: Palgrave Macmillan; 2010. 3. Calma T. Closing the Gap: Campaign for Aboriginal and Torres Strait Islander health inequality by 2030. Canberra, Australia; 2008. 4. Close the Gap Coalition. Close The Gap Campaign. 2007; http://www.closethegap.com.au/ (accessed June 12, 2010). 5. World Health Organization. Ottawa Charter for Health Promotion. Ottawa, Canada: WHO; 1986. 6. McLennan V, Khavarpour F. Culturally appropriate health promotion: its meaning and application in Aboriginal communities. Health Promot J Austr. 2004; 15(3): 237–239. 7. Thorpe A. Elders Panel. In: Aboriginal Health Panel Discussion, Melbourne, Australia: VACCHO; 2010.
8. HealthInfoNet. Summary of developments in indigenous health promotion. 2005; http://www. healthinfonet.ecu.edu.au/health-systems/healthpromotion/reviews/our-review (accessed July 4, 2010). 9. Stewart I, Wall S. The forgotten smokers. Aboriginal smoking: issues and responses. Canberra, Australia: Australian Medical Association and Australian Pharmaceutical Manufacturers’ Association; 2000. 10. Eckersley R. Culture, spirituality, religion and health: looking at the big picture. Med J Austr. 2007; 186(10): S54-S60. 11. Williams DR, Sternthal MJ. Spirituality, religion and health: evidence and research directions. Med J Austr. 2007; 186(Supp 10): S47-S50. 12. Bita N. Tom Calma to run Indigenous Push. The Australian. 2010. 13. Briggs VL, Lindorff K, Ivers RG. Aboriginal and Torres Strait Islander Australians and tobacco. Tob Control. 2003; 12. 14. Ivers R. An evidence-based approach to planning tobacco interventions for Aboriginal people. Drug Alcohol Rev. 2004; (23): 5-9. 15. Angin G. Community Newsletter on Tobacco Control. 2006; 3; www.ceitec.org.au/files/ceitec_ admin_7/ceitec_ADMIN_downloads/CEITEC_ Newsletter_3.pdf (accessed July 4, 2010). 16. Lindorff K. Tobacco – time for action. National Aboriginal and Torres Strait Islander Tobacco Control Project. Final Report. Canberra, Australia: National Aboriginal Community Controlled Health Organisation (NACCHO); 2002. 17. McLennan W. National Aboriginal and Torres Strait Islander Survey NATSIS: Health of Indigenous Australians. Canberra, Australia: Australian Bureau of Statistics; 1996.
IUHPE – Global Health Promotion Vol. 19, No. 2 2012
Downloaded from ped.sagepub.com at TEXAS A&M UNIV TEXARKANA on August 20, 2015
2012
GHP19210.1177/1757975912441230Demaio et al.Global Health Promotion
Commentary Appropriate health promotion for Australian Aboriginal and Torres Strait Islander communities: crucial for closing the gap Alessandro Demaio1, Marlene Drysdale2 and Maximilian de Courten1
Abstract: Health promotion for Australian Aboriginal and Torres Strait Islander communities and their people has generally had limited efficacy and poor sustainability. It has largely failed to recognise and appreciate the importance of local cultures and continues to have minimal emphasis on capacity building, community empowerment and local ownership. Culturally Appropriate Health Promotion is a framework of principles developed in 2008 with the World Health Organization and the Global Alliance for Health Promotion. It serves as a guide for community-focused health promotion practice to be built on and shaped by the respect for understanding and utilisation of local knowledge and culture. Culturally Appropriate Health Promotion is not about targeting, intervening or responding. Rather, it encourages health programme planners and policymakers to have a greater understanding, respect, a sense of empowerment and collaboration with communities, and their sociocultural environment to improve health. This commentary aims to examine and apply the eight principles of Culturally Appropriate Health Promotion to the Australian Aboriginal and Torres Strait Islander context. It proposes a widespread adoption of the framework for a more respectful, collaborative, locally suitable and therefore appropriate approach to Australian Aboriginal and Torres Strait Islander health promotion. (Global Health Promotion, 2012; 19(2): 58–62) Keywords: Advocacy, collaboration, partnership, community, equity and social justice, health promotion, health determinants, policy, programme planning and management
Introduction Aboriginal and Torres Strait Islander Australians (Aboriginals) are known to suffer the poorest health of any group within Australia and, arguably, within the developed world’s First Nations people (1). Taylor wrote: It is not credible to suggest that one of the wealthiest nations of the world cannot solve a health crisis affecting less than 3% of its citizens (2). This chronic crisis requires new approaches and strategies which are built in partnership with Australian Aboriginal communities aimed at consciously Closing the Gap (3) in Aboriginal ill health.
The current Aboriginal health promotion campaigns including Closing the Gap (3) follow the Ottawa Charter principles to advocate, enable and mediate. They highlight that strategies and programmes should be adapted to the local communities (4). The authors of this paper go much further and call for health promotion practice to be built on and shaped by the respect for and understanding of local communities, their culture as well as their knowledge. Culturally Appropriate Health Promotion (CAHP) provides an empirical framework for this paradigm shift (5). CAHP is not simply about targeting, intervening or responding. Rather, it strives for the understanding, empowerment and respect of communities and their sociocultural environments. It aims to sustainably influence health
1. School of Global Health, University of Copenhagen, Copenhagen, Denmark. Correspondence to: Alexandre Demaio, [email protected] 2. Indigenous Health Committee and Indigenous Health Unit, Monash University, Monash, Australia.
Global Health Promotion 1757-9759; Vol 19(2): 58 –62; 441230 Copyright © The Author(s) 2012, Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1757975912441230 http://ghp.sagepub.com Downloaded from ped.sagepub.com at TEXAS A&M UNIV TEXARKANA on August 20, 2015
A. Demaio et al.
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Table 1. Culturally appropriate health promotion principles 1. Community involvement, consultation and empowerment 2. Socioculturally tailored health promotion techniques 3. Community evaluation and feedback in real time 4. The utilisation of local communication techniques 5. Maximisation of both the spoken word and the local tongue 6. Sustainable health development and community health autonomy 7. Holistic in nature, addressing the needs of the whole person 8. Spirituality and social connectedness as health determinants
and its determinates through the appreciation of local wisdom and in collaboration with local people. Health promotion for Aboriginal communities has to date had generally limited efficacy and poor sustainability (6). Largely failing to recognise and appreciate the importance of local cultures, it continues to place minimal emphasis on capacity building or community strengthening and ownership (7). Moving forward, health promotion within Aboriginal communities needs to celebrate the diversity of cultures within this population rather than seeing it as a hurdle. Culture and its facets should be regarded as important social determinants and possible catalysts for health. These cultural determinants include socioeconomic circumstances, numerous languages and dialects, geographic location, and importantly the consequences of colonisation (8). This commentary examines and applies the eight principles of Culturally Appropriate Health Promotion to the Australian Aboriginal context. This framework was developed by the lead author of this paper in 2008 under the direction of the World Health Organization and the NGO Alliance for Health Promotion (5).
Applying CAHP principles to Australian Aboriginal health Community involvement, consultation and empowerment There is a need to recognise and acknowledge the diversity of Aboriginal communities and their individual cultures, rather than assuming cultural homogeneity. Communities must be involved in every stage of health programme development, implementation and evaluation and play a meaningful, integral role. Com munities should be involved from the programme
outset. Achieving this requires health promotion to engage with local communities, organisations and individuals at an early stage. This can be achieved through, but not limited to, community consultation and committees, focus groups, surveys, interviews and local advisory groups. Health promotion planners need to recognise the value of existing community assets and build upon them sustainably. These assets may include aspects of the culture itself, which could lead to catalysing health improvements, or encourage key community members to assist in building community knowledge, motivation or mobilisation.
Socioculturally tailored health promotion techniques The chosen health promotion methodology should reflect the local community, their needs and their cultural values, rather than those of the research team or health promotion organisation. Health promotion must be community-focused, based around culturally appropriate messages and should reflect the priorities of the community. It is also crucial that health promotion programmes recognise there is much to learn from local communities themselves. This knowledge should be reflected in programmes and act as a framework for their methodological development. For example, recognition of traditional healers, their knowledge and their holistic approach to healing could provide a valuable approach for health promotion strategies.
Community evaluation and feedback in real time Part of the CAHP ideology is a capacity for commu nity evaluation, providing feedback of programmes IUHPE – Global Health Promotion Vol. 19, No. 2 2012
Downloaded from ped.sagepub.com at TEXAS A&M UNIV TEXARKANA on August 20, 2015
Commentary
60
on current community opinions, efficacy and interpretation of programmes. Community meetings and participation in advisory boards are crucial to engaging communities and ensuring local control and ownership. This creates an opportunity for timely programme improvement, allowing health promotion coordinators to adapt and reflect the local community’s needs. It should be recognised that communities work within their own timeframes and not necessarily those of the health promotion programme. Therefore, programme managers need to allocate adequate time to involve the community rather than have a rush in rush out approach.
The utilisation of local communication techniques Communication and subsequent interpretation of information are key processes in health promotion. As local communication techniques vary greatly between communities, beyond the spoken language, programme communication techniques must reflect the individual community demographics, culture and values. The use of symbols and area-specific artwork that engage local artists may result in more effective and appropriate communication with communities (9). Recognising and understanding the complex communication pathways in Aboriginal communities is important. An example would be the importance of gender and gender roles, which may result in a young woman seeking female-only healthcare staff. Such a request should be respected and viewed in its wider cultural frame. Another example is the importance of valuing and engaging community Elders who are leaders, gatekeepers and protectors for their community. It is only through mapping and understanding these local communication pathways, that effective health promotion strategies can be developed.
Maximisation of both the spoken word and the local tongue CAHP aims to minimise the reliance of health promotion programmes on written text. In addition, it utilises local language and, where possible, regional dialects and their individual phrases, slangs and idioms. Health promotion should understand, celebrate and utilise local language and
its cultural framing, avoiding complex or jargonistic text, which is exclusive and disempowering to communities.
Sustainable health development and community health autonomy Opportunities for up-skilling local researchers, allowing replication or adaptation of health promotion programmes beyond their final endpoints, should be sought. When engaging communities, programmes that build local capacity allow communities to have control over future programmes and their own health. This includes recognising community assets early, valuing them, strengthening them and building upon them. Health promotion planners should have the ultimate aim of programme self-sustainability, community autonomy and health ownership. Programme sustainability and Aboriginal ownership are essential to improving indigenous health long-term.
Holistic in nature, addressing the needs of the whole person It is recognised that health status is largely determined by the complex interplay of sociocultural, economic and educational determinants. Therefore health promotion must aim to address and alleviate problems of poverty, illiteracy and illness concurrently. A holistic approach to health is even more crucial in an Aboriginal setting where programmes too often focus on a biomedical, vertical and fragmented strategy. Health promotion programmes must engage the whole community and focus on their needs. Social determinants of health including housing, education, unemployment and poverty need to be co-addressed through and within health programmes. It should be recognised that health promotion can provide a powerful vehicle for empowering communities to overcome these determinants and improve their own health.
Spirituality and social connectedness as health determinants Spirituality and a sense of social connection have a great influence on health and wellbeing at an individual level (10). This is amplified when applied
IUHPE – Global Health Promotion Vol. 19, No. 2 2012
Downloaded from ped.sagepub.com at TEXAS A&M UNIV TEXARKANA on August 20, 2015
A. Demaio et al.
to a population and can have major downstream effects in regards to nutrition, exercise and stress. Health promotion programmes should recognise the importance of and strengthening community spirituality and social connectedness as key determinants of Aboriginal health (11). The connection of Aboriginal people to their land, place and space needs to be understood and seen as a basis for health, social cohesion and collective wellbeing.
Applying the principles: Australian quit smoking campaign The Quit Smoking Campaign aimed to reduce smoking prevalence in all Australian communities. Whilst being widely successful, it had little impact on Aboriginal smoking rates where the prevalence continues to be more than double that of the general population (12). One reason for this failure was that it did not appropriately engage with Aboriginal communities and their culture (13). A recent audit of tobacco control programmes showed that whilst many agencies ‘adapted’ materials specifically for a perceived homogenous Aboriginal audience, none of them used local languages or dialects (13). Such blanket approach tailoring has not sought to understand communities, their knowledge or their traditions. These traditions can in part explain the high smoking rates in these communities, including tobacco playing a role in cultural ceremonies and important cultural beliefs that act as direct barriers to nicotine replacement use (14). Applying the principles of CAHP, communities should have been involved in campaign design from the beginning (Principles 1 and 3). Had they been involved, smaller-scale, more appropriate programmes may have been developed. Better reflecting the diverse nature of Aboriginal communities, these microcampaigns would have been more flexible to the local needs, cultures and communication methods of their people (Principle 2). Including and empowering communities, local leaders and their formal and informal healthcare services are key elements to promoting health in Aboriginal communities (15) (Principles 1 and 6). Greater community involvement and ownership leads to opportunities for capacity building within a community. Health programme planners must work with communities to build their own responses to smoking, rather than imposing a national campaign. This would afford skills,
61
knowledge and the tools for more meaningful and sustainable campaign outcomes (Principle 6). How information is communicated is also important (Principles 2 and 5). Campaigns that recognise and reflect the particular community-level communication pathways and hierarchy would be better able to combat smoking (Principle 4). In Aboriginal communities, this could see traditional Elders engaged as ambassadors of health promotion (16). Programmes that include a focus on older, prominent community members not only aim to reduce ill health in a highrisk group but may also initiate widespread declines in smoking behaviour through important rolemodelling (17). The Forgotten Smoker, a report from the Australian Medical Association, found that in contrast to non-Aboriginals, many Aboriginal communities find it harder to connect with and relate to famous health role models because they are not perceived as having to face the everyday stresses of an ordinary life. This report also explained that health promotion for an Aboriginal audience, particularly Aboriginal youth, should emphasise family themes and use story lines in order to enhance their reach and penetration (9) (Principle 2). Tom Calma, former Australian Race and Social Justice Commissioner, pragmatically states ‘we need a different message for indigenous people’. The above example of current anti-smoking campaigns supports this view and highlights the need for a more intelligent, respectful and thoughtful approach to Aboriginal health promotion.
Conclusion This commentary examined and applied the principles of Culturally Appropriate Health Promotion to the Australian Aboriginal and Torres Strait Islander context. Its authors propose the adoption of this framework to achieve more respectful, collaborative and locally acceptable approaches to Aboriginal health promotion. Health promotion strategies should value Australian Aboriginal communities as partners who must be intimately and extensively involved in all stages of the health promotion process. Furthermore, health promoters should seek to understand and apply the knowledge and expertise of communities, to all levels of their practice. Ignoring communities, particularly at the early stages of programme development and IUHPE – Global Health Promotion Vol. 19, No. 2 2012
Downloaded from ped.sagepub.com at TEXAS A&M UNIV TEXARKANA on August 20, 2015
Commentary
62
implementation can lead to a programme–community disconnect. This will be reflected in the programme’s ability to engage with the local community and ultimately deliver on its aims for better health. Governments, policymakers and the health promo tion planners should strive for Culturally Appropriate Health Promotion. That is, considering target populations as partners and health interventions as partnerships. These communities should be empowered through health promotion activities that aim to share knowledge rather than impart it and to develop sustainable, community-owned, locally driven and culturally grounded health improvements. References 1. Demaio A. Local Wisdom and Health Promotion; Barrier or Catalyst. Geneva, Switzerland: World Health Organization; 2008. 2. Taylor K, Guerin P. Health care and Indigenous Australians: Cultural Safety in Practice. Australia: Palgrave Macmillan; 2010. 3. Calma T. Closing the Gap: Campaign for Aboriginal and Torres Strait Islander health inequality by 2030. Canberra, Australia; 2008. 4. Close the Gap Coalition. Close The Gap Campaign. 2007; http://www.closethegap.com.au/ (accessed June 12, 2010). 5. World Health Organization. Ottawa Charter for Health Promotion. Ottawa, Canada: WHO; 1986. 6. McLennan V, Khavarpour F. Culturally appropriate health promotion: its meaning and application in Aboriginal communities. Health Promot J Austr. 2004; 15(3): 237–239. 7. Thorpe A. Elders Panel. In: Aboriginal Health Panel Discussion, Melbourne, Australia: VACCHO; 2010.
8. HealthInfoNet. Summary of developments in indigenous health promotion. 2005; http://www. healthinfonet.ecu.edu.au/health-systems/healthpromotion/reviews/our-review (accessed July 4, 2010). 9. Stewart I, Wall S. The forgotten smokers. Aboriginal smoking: issues and responses. Canberra, Australia: Australian Medical Association and Australian Pharmaceutical Manufacturers’ Association; 2000. 10. Eckersley R. Culture, spirituality, religion and health: looking at the big picture. Med J Austr. 2007; 186(10): S54-S60. 11. Williams DR, Sternthal MJ. Spirituality, religion and health: evidence and research directions. Med J Austr. 2007; 186(Supp 10): S47-S50. 12. Bita N. Tom Calma to run Indigenous Push. The Australian. 2010. 13. Briggs VL, Lindorff K, Ivers RG. Aboriginal and Torres Strait Islander Australians and tobacco. Tob Control. 2003; 12. 14. Ivers R. An evidence-based approach to planning tobacco interventions for Aboriginal people. Drug Alcohol Rev. 2004; (23): 5-9. 15. Angin G. Community Newsletter on Tobacco Control. 2006; 3; www.ceitec.org.au/files/ceitec_ admin_7/ceitec_ADMIN_downloads/CEITEC_ Newsletter_3.pdf (accessed July 4, 2010). 16. Lindorff K. Tobacco – time for action. National Aboriginal and Torres Strait Islander Tobacco Control Project. Final Report. Canberra, Australia: National Aboriginal Community Controlled Health Organisation (NACCHO); 2002. 17. McLennan W. National Aboriginal and Torres Strait Islander Survey NATSIS: Health of Indigenous Australians. Canberra, Australia: Australian Bureau of Statistics; 1996.
IUHPE – Global Health Promotion Vol. 19, No. 2 2012
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