Health & Place 34 (2015) 54–62
Contents lists available at ScienceDirect
Health & Place journal homepage: www.elsevier.com/locate/healthplace
Development of the good food planning tool: A food system approach to food security in indigenous Australian remote communities Julie Brimblecombe a,n, Christel van den Boogaard a, Beverley Wood a, Selma C Liberato a, Jacqui Brown a, Adam Barnes e, Alison Rogers b, John Coveney a,c, Jan Ritchie a,d, Ross Bailie a a
Menzies School of Health Research, Darwin, NT, Australia The Fred Hollows Foundation, Indigenous Australia Program, Darwin, NT, Australia c Flinders University, Adelaide, SA, Australia d University of New South Wales, Sydney, NSW, Australia e Northern Territory Department of Health, Darwin, NT, Australia b
art ic l e i nf o
a b s t r a c t
Article history: Received 4 September 2014 Received in revised form 3 February 2015 Accepted 11 March 2015
Few frameworks exist to assist food system planning, especially for Indigenous Australian remote communities. We developed a Good Food Planning Tool to support stakeholders to collectively plan and take action for local food system improvement. Development occurred over a four-year period through an evolving four phase participatory process that included literature review, several meetings with representatives of various organisations and communities and application of the Tool with multi-sector groups in each of four Indigenous Australian remote communities. A diverse range of 148 stakeholders, 78 of whom were Indigenous, had input to its development. Five food system domains: (i) Leadership and partnerships; (ii) Traditional food and local food production; (iii) Food businesses; (iv) Buildings, public places and transport; (v) Community and services and 28 activity areas form the framework of the Tool. The Good Food Planning Tool provides a useful framework to facilitate collective appraisal of the food system and to identify opportunities for food system improvement in Indigenous Australian remote communities, with potential for adaptation for wider application. & 2015 Elsevier Ltd. All rights reserved.
Keywords: Food systems Food security Indigenous Australia Food system assessment Multi-sectoral
1. Introduction Local food systems for Indigenous Australians have changed significantly in recent history (Lee, 1996). Indigenous Australian remote communities now depend largely on store purchased foods and to a lesser extent on traditionally collected foods and locally produced foods (Brimblecombe et al., 2013). Change in local food systems has come at a great cost to the health of communities and individuals, with food insecurity (AIHW, 2011) and dietrelated conditions (such as overweight, obesity, cardiovascular disease, type 2 diabetes) now major contributors to the serious health gap between Indigenous and non-Indigenous Australians (Vos et al., 2009). It is well accepted that reliance on individual level approaches and/or a focus on mechanisms within a single area of the food system are not enough to improve food security and stem burgeoning diet related conditions; major changes to the food environment are necessary (Swinburn and Egger, 2002). This
n Corresponding author at: Menzies School of Health Research, John Mathews Building (58), Royal Darwin Hospital, PO Box 41096, Casuarina, NT 0811, Australia. Tel.: þ 61 8 89228577; fax: þ 61 8 89275187. E-mail address: [email protected] (J. Brimblecombe).
http://dx.doi.org/10.1016/j.healthplace.2015.03.006 1353-8292/& 2015 Elsevier Ltd. All rights reserved.
requires taking a holistic view to consider the multiple areas of the food system and to change the relevant societal, economic and physical drivers in a direction that is health promoting (Signal et al., 2013). The ways to do this are not straightforward as food environments are complex and dynamic (Swinburn et al., 2005). Evidence-based strategies for addressing the burden of dietrelated conditions are also limited (Swinburn et al., 2005; Giskes et al., 2007, 2011; Holsten, 2009; Caspi et al., 2012). Decisionmaking processes that combine best available evidence and local knowledge to develop a course of action and to create new perspectives and narratives that impact on how people think and act are receiving increasing attention (Swinburn et al., 2005; Bushe and Marshak, 2009; Edvardsson et al., 2012). These approaches are believed to have the greatest chance of responding to the changing nature of the food environment and in developing strategies that are comprehensive, contextually relevant and suited to the community of concern (Swinburn and Egger, 2002). In the context of Indigenous Australian remote communities, two innovative system approaches to planning that have potential application to local food systems have been used to improve quality of primary health care and essential service delivery (Bailie et al., 2007; McDonald et al., 2013). These draw on the principles of quality improvement and participatory learning
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(Bailie et al., 2013; WHO, 2007) and use a systems assessment tool to support stakeholders to collectively appraise practice against a pre-defined set of best practice goals (Bailie et al., 2007). From this, an action plan is developed and data on practice and outcome measures are collected to provide feedback on performance. A cornerstone of these system approaches is the focus on achieving quality improvement through a structured ongoing cycle of participatory assessment, planning and action, to achieve stepby-step incremental improvement. Through this process of discussion and analysis stakeholders incrementally build their knowledge of the nature of the system and how it behaves. As far as we know there have been no initiatives in the Indigenous Australian remote community context that have sought to engage a group of stakeholders at the local level in a systematic and ongoing process of decision-making for food system improvement. Yet the few community-based interventions in this context shown to positively impact on diet-related conditions point towards the importance of addressing multiple areas of the food system (Lee et al., 1994; Rowley et al., 2000; Black et al., 2013a, 2013b), and involving local stakeholders and community leaders in planning, implementation and evaluation activities (Black, 2007). The unique history, governance structures and other characteristics of the food environments of Indigenous Australian remote communities need to be considered in food system decisionmaking processes as these can offer both opportunities and challenges. Different geographical locations exhibit unique characteristics that necessitate special consideration. There are over 160 discrete communities in remote Indigenous Australia with populations of more than 100 people that are located over vast tracts of the nation and are geographically isolated from larger urban centres (ABS, 2010). These communities have all experienced a recent history of European invasion, colonisation and oppression and continue the struggle of retaining their culture and rights in a wider society where a western worldview dominates. Communities have retained structures of Indigenous leadership that co-exist with non-indigenous governance structures. Further important characteristics are that most communities are small in population size and yet have a large ratio of and high turnover of non-Indigenous service providers (such as medical professionals, public health nutritionists, aged-care managers, horticulturalists, store managers) per capita; and, also, that food hunting and gathering plays an important economic, dietary and cultural role in most communities. The few food environment related assessment tools (Wood and McDowell, 2009; Swinburn
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et al., 1999; DFID, 2013; Tansey and Worsley, 1995; Kelly et al., 2011; McKinnon et al., 2009; Pomerleau et al., 2013; Glanz et al., 2007; NEAT, 2014) that exist do not capture all elements of this unique environment nor have they been purposefully developed as part of an integrated quality improvement process. In response to a heightened interest to redress food security in Indigenous remote communities by the Australian government and community leaders seeking opportunity to ‘have a say’ in the development and implementation of food security initiatives, we aimed to develop a tool structure and implementation approach that would enable the engagement of community people and other stakeholders to identify gaps, barriers and opportunities for improvement of the food system, as part of an integrated quality improvement process. The development of the Good Food Planning Tool (GFPT) occurred as part of the Good Food Systems: Good Food for All Project (GFS Project)—a five-year case study (2009– 2013) that aimed to assist stakeholders, including Indigenous community residents, to collectively identify food system challenges and opportunities to improve food security (i.e., food availability, access and utilisation) over time. This article describes the development of the GFPT and its implementation in four communities.
2. Methods 2.1. Good food planning tool development: Evolving participatory process The GFPT evolved through a four phase participatory process as shown in Table 1. It was informed by multiple sources of data collected through literature review, expert review of an early version of the GFPT, four stakeholder meetings with Indigenous and non-Indigenous stakeholders (for test of relevance and validity), application with food interest groups in each of the four Indigenous communities as part of the GFS project (for test of application), and experience gained by all. 2.1.1. Study setting Two of the Indigenous Australian remote communities that participated in the GFS project and whose members contributed to the development of the GFPT were situated on the North Australian coast, another was inland from the coast and a fourth was in the Central Australian desert. The communities varied in size
Table 1 Outline of the GFPT development phases and associated dates, activity and aim. Phase
Date
Phase 1: April-Sept 2009 Development
Activity
Aim
Literature review Expert review n¼ 22 (2 Aboriginal participants)
Determine food system domains, activity areas, corresponding best practice characteristics and application process Check the activity areas and corresponding best practices with food delivery, food retail and food policy experts Check all aspects of the tool Inductively identify activity areas and corresponding best practice characteristics for each food system domain Compare and contrast these against GFPT Determine and test process for Tool application
Phase 2: Test of 29th Sept 2009 Meeting 1a b n¼ 13 (3 Aboriginal participants) 16th-17th Feb 2010 Meeting 2ab n¼ 27 (15 Aboriginal participants) relevance
Phase 3: Test of 2nd-4th Nov 2011 validity
Phase 4: Refinement
Meeting 3a
b
n¼ 20 (14 Aboriginal participants)
Annually 2010-2013 Annual planning meetings with community-based food-interest groups in each of the four communitiesa n¼ 26-42 Sept 2012 Data review
Meeting 4a n ¼7 (4 Aboriginal community coordinators) a b
Review all data for any emerging and/or divergent food system domains, activity areas or best practice characteristics Check terminology and graphics
Participant numbers include the facilitators and/or members of the research team who also provided expert content knowledge. These meetings were all urban-based in contrast to the annual planning meetings that were community-based and community specific.
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(250 to over 2000 residents), were classified as very remote (ABS, 2001, 2011) (accessible by long distance road travel, by small aircraft or boat), and socio-economically disadvantaged (ABS, 2013). The four communities were of Aboriginal heritage and diverse in cultural practices. Multiple languages were spoken in each community and English was the main language in only one community. All four communities were serviced by a local government authority and had a community owned store, a school, arts community, health centre, employment program and other services such as aged-care, sports and recreation and child-care. Three of the four communities had one or more additional food outlets (for example—fast food outlet, club, convenience store, butchery). Food delivery to the communities was by long distance road (weekly or fortnightly) or by weekly barge and aircraft. Fresh goods were usually delivered by aircraft to one community in the wet season ( October to May). Extreme weather conditions periodically disrupted the supply of food to all communities. 2.1.2. Stakeholders A diverse range of Indigenous and non-Indigenous stakeholders with different roles in the food system were invited to have input to the development of the GFPT through review of an early version of the GFPT and/or participation in a series of four urban-based meetings. These stakeholders included residents from the four GFS study communities and other stakeholders also with expertise in aspects of food systems. 2.1.3. Community multi-sector groups (the food-interest groups) In each community, the GFS Project supported stakeholders with an interest in the community food system to participate in annual planning meetings (of 2 half days) to appraise their food system and prioritise a set of actions (for commitment to implementation) using the GFPT (or developing versions). Four annual planning meetings took place over the course of the GFS Project in two communities, with three such meetings in the third community and one only in the remaining site. Participation was voluntary and open to any community member (both Indigenous and non-Indigenous) or external stakeholder who had an interest in, or who might impact on the local food system. A member of the research team (Project facilitator) and a local resident Aboriginal community co-ordinator (employed by the Project) facilitated these meetings. The GFPT was progressively refined over several versions during the course of the GFS Project. 2.1.3.1. Ethics. Ethics approval for all aspects of the Good Food Systems: Good Food for All Project was attained from the Human Research Ethics Committee (HREC) of the Northern Territory Department of Health and Menzies School of Health Research (ref. HREC 09/07), Cairns and Hinterland Health Service District Ethics Committee (ref. HREC/10/QCH/71-678) and the Central Australian HREC (ref 2009.02.02). Signed partnership agreements were negotiated with participating organisations and communities.
3. Results 3.1. Phase 1. Development of the first versions of the GFPT 3.1.1. Literature review We drew from existing system tools (Bailie et al., 2007, 2013; McDonald et al., 2013) and food environment related assessment tools (Wood and McDowell, 2009; Swinburn et al., 1999; DFID, 2013) to determine tool structure and content. The structure selected for the GFPT was that of the systems assessment tool successfully used in the primary health care setting in the Indigenous Australian
remote community context (Bailie et al., 2007). System domains (such as ‘food businesses’), activity areas for each domain (such as the placement and promotion of food in the ‘food businesses’ domain) and best practice characteristics for each activity area (such as for placement—“Food is placed in a way that encourages healthy food choices” and for promotion—“Healthy food is promoted in the store”) were then identified and continually refined over the course of Tool development. In doing this, the first aim in development of the GFPT was to systematically identify the range of activities in the Indigenous Australian remote community context that related to each of the dimensions of food security (food availability, access and utilisation) for each function of a food system (Tansey and Worsley, 1995) (food collection/growing to waste disposal and recycling) and in each area of the environment (socio-cultural, physical, economic and political and natural) (Wood and McDowell, 2009; Swinburn et al., 1999; Sacks et al., 2008; Environments for Health, 2001). This occurred first through a scan of published and grey literature to identify: (i) the factors considered to influence food security in the Indigenous Australian remote community context (Brimblecombe et al., 2014; Gorton et al., 2010); (ii) related food policies, programs, services and guidelines; and, (iii) practices considered to influence the consumer food environment (Glanz and Yaroch, 2004) and traditional food access and use (Woodley et al., 2009).
3.1.2. Expert review We then elicited the views of 22 expert stakeholders, representing the remote community food retail industry (7), food wholesalers (1), academia (3), national nutrition policy (1), Australian and territory government (5) and non-government organisations (5), through written and oral feedback, on both the proposed structure and content of the GFPT and its application. The following recommendations were made: (1) Include all areas of the local food system that relate to food security including traditional food and local food production; (2) In its application, identify actions based on what is in the best interest of the community, community capacity to address the problems, and local leadership capacity; (3) Link the food system to health indicators; (4) Include evidence-based scenarios of how to achieve improvement in the different activity areas and show where linkages within the system occur; (5) Keep the GFPT brief, comprehensive and non-prescriptive, with the use of plain English and graphics; (6) Ensure strong community representation in community level multi-sector food interest groups and address issues as determined by community decision; (7) Support food system improvement from the angle of ‘goalsetting’ and establish a shared vision for the food system with the group of stakeholders. As a result of this feedback, the scope of the GFPT was broadened from an initial focus on the community store (as the primary source of food in a remote community) and its community-wide linkages, to include all areas of activity relating to the different food system functions including the production and procurement of local and traditional foods.
3.2. Phase 2. Test of relevance for the GFPT Thirteen food retail and policy experts participated in a first meeting to identify and reach consensus on activity areas and best practice characteristics for the food system functions relating to food delivery, food-related policy and food retailing (Table 1).
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These were then cross-checked against the GFPT and modifications made accordingly. In the second meeting, 27 stakeholders including 16 residents of the four GFS communities and 11 people with expertise in health promotion, public health nutrition, food security policy, food systems, store governance and retail practice reviewed each domain of the GFPT alongside the activity areas and best practice characteristics and provided comment on relevance to the Indigenous Australian remote community context, clarity of terminology and graphic images, and gaps. Participants preferred food system activities to be grouped by the setting or area of responsibility rather than by the socio-cultural, physical, economic, political and natural aspects of the environment. For example, activities relating to food businesses such as the availability of a full range of healthy food and placement of foods to encourage healthy food purchasing, were then grouped within a domain called “food businesses” rather than in a domain called “physical environment”.
3.3. Phase 3. Test of validity for the GFPT Twenty people representing the four participating communities (and Good Food Systems Project facilitators) with most being Aboriginal then participated in a third meeting to test if the domain and activity areas of the evolving GFPT corresponded with areas
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identified by Indigenous community representatives as relevant to their local food systems. To begin, each community group of three to six people expressed their view of their local food system through use of drawings and existing photos and presented this view to the whole group. The significance of traditional food in the local food system was apparent and depicted separately to the settings responsible for different aspects of the food system (such as the store, the local government services, the school, and the health centre). The whole group was then invited to inductively identify a set of activity areas perceived as important to food security for each of the five food system domains included in the evolving GFPT. The question asked to participants for each domain was: “what activity would you see in your community if this area of the food system was really strong?” The community derived activity areas are shown in Table 2. They were broadly consistent with the activity areas and the best practice characteristics identified through the previous tool development phases although different terminology was used.
3.3.1. Application of GFPT with community-based food-interest groups In each of the four participating communities, 26–42 different Indigenous and non-Indigenous stakeholders participated in at least one annual planning meeting over the GFS Project period (2009–2013) and used the GFPT. Through these meetings a facilitated process to support the collective use of the GFPT to
Table 2 Activity areas important to food security in several food system domains as identified by community representatives and the final GFPT. Food system domain
Activity areas (as identified by community representatives)
Activity areas (final GFPT)
Leadership and partnerships
Community needs assessment; strong voices in community; consulting with Elders Sharing of resources; working together and strong communication Elders participating in decision-making
Leadership Good linking and partnerships Community plans and policies/ community ownership Local workforce investment
Leadership training; employment and capacity building; skill development in home maintenance; employment of Indigenous Essential Service Officers Sector support from local government authority Knowledge translation from elders; caring for elders, so they can pass on knowledge; information collected and reported on nutritional status of community Traditional foods and Care and management of country; conservation practices in place; laws and regulations that local food production protect traditional food and Indigenous land and water rights Access to traditional food supported, e.g., hunting permits for community people easily accessed Teaching in two ways in schools and on country; programs in place to develop knowledge and skills of youth Local food production e.g., market gardens; banana farm Community and Community-wide promotion and support for healthy eating; parents role-modelling healthy services eating Development of cooking skills; access to meaningful nutrition information; schools teaching nutrition; school breakfast program in place; local media broadcasting health messages; support for festivals/ health fairs and culture week Nutrition programs for: young women, mothers and families of children with growth and development issues, and for people with diet-related conditions such as type 2 diabetes Community services promoting healthy eating Support for aged-care services Buildings, public places Adequate buildings to support healthy eating and transport Families working together for a healthy home; adequate housing and infrastructure; adequate household food storage and food preparation facilities; house owner taking responsibility for upkeep of home Adequate, good quality water supply; good and reliable power supply Frequent and adequate food delivery to community Food businesses Community leaders ensure that store is of a high standard Well supported staff; food safety training for staff Strong and functioning store committee; community support for store committee; compliance with workplace health and safety regulations; compliance with food safety practices; no dogs in store Adequate infrastructure (e.g., air-conditioning/ refrigeration) No out-of-date food in shops; healthy food available when shop opens; fresh food (such as milk and bread) available; healthy takeaway options available; budgeting and financial support available Pricing encourages healthy food purchases (e.g., mark down on healthy foods (fruit and veg and other foods)) Healthy food promoted (e.g., store shelf-talkers, posters, food signs, fruit bowl at counter)
Commitment to action Good information and feedback systems Care and management Traditional food promotion and use; Things you need to go hunting and collecting Passing on knowledge Local food production Community support Promotion activities and training
Health services support Food services Buildings and public places Homes
Safe drinking water and power Transport and food delivery Community support People in food businesses Policies and management support Places (buildings) Products
Prices Promotion and placement
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appraise the food system and develop a plan of action evolved (Box 1). Facilitated by the project community co-ordinators and/or project facilitator (JB, JBr, CB or AB), stakeholders in all four communities were collectively able to use the GFPT to assess their community local food system. They could score each food system activity area using the qualitative ripple scoring system developed through the GFS project (Brimblecombe JvdB et al., 2014) and shown in Box 2. This participatory and visual method of appraising domains and activities for our purposes was found to be more acceptable to participants than the original linear scoring scale of 0 to 11 based on the systems assessment tool used in the Indigenous Australian primary health care setting (Bailie et al., 2007). The best practice characteristics for each activity area helped facilitate
discussion on the strength of each activity area. Reasons given by the group of stakeholders for the scoring of each activity area were recorded, together with the discussions of challenges and opportunities for improvement and the long list of identified actions. Only in two communities did time permit prioritisation of actions. This then contributed to the development of an action plan (with time frame and responsibilities) to be used in subsequent review meetings as part of the quality improvement process.
Box 1–The steps used in facilitation of the GFPT to appraise the food system and develop a plan of action. More detail is available in the Good Food Planning Tool and guide for users (Brimblecombe et al., 2014). – Explain the structure of the GFPT and the appraisal process – For each food system domain, provide a verbal description of each activity area using the best practice characteristics as examples – Show the visual for the activity area being discussed, and ask the group to reflect and comment on how strongly they see the activity area performing in their community – After listening to and recording the group’s discussion, place the visual on one of five circles of a ripple diagram (where the outer circle represents very strong/fully developed and the inner circle, just developing) that seems to best represent people’s comments and ask if this matches with their perception; and then, – Manage the discussion until consensus is reached and write agreed discussion points on a sticky note to then also display on the ripple; – Record on a sticky note any actions or strategies to strengthen the area being discussed that arise in the discussion – Continue to discuss each activity area for each domain and record the appraisal process using a different ripple for each domain – Take a photo for future comparison with the next food system appraisal – Manage a discussion to further identify actions – Use a participatory tool such as the ten seed technique (Jayakaran, 2002) or pocket chart (Donelly, 2010) to prioritise actions and define a plan of action.
3.4. Phase 4. Refinement of the GFPT 3.4.1. Information review Three authors (JB, CB and SL) reviewed and cross-checked all data collected from the activities of the previous Phases (1–3) and from the food system appraisals and actions plans and/or list of actions developed through the GFS annual planning meetings to identify any emerging and/or divergent food system domains, activity areas or best practice characteristics and any other issues including interpretation. No emerging new themes or activity areas were identified. A number of inter-related activity areas were merged with more detail on the characteristics of best practice included.
Box 2 An example of the appraisal of the “food businesses” domain, by a community food-interest group; using the ripple scoring system. Based on a facilitated dialogue and consensus by the group, a picture card representing each activity area is placed on a circle of the ripple where the outer circle represents very strong/fully developed and the inner circle, just developing. This example shows that in this community, the group of stakeholders viewed practices relating to food price and community support for store business as areas that needed most strengthening in their community.
3.4.2. Community review The last step in achieving a set of domains, activity areas and best practice characteristics that reflected the food systems in the participating communities was to review the last version of the GFPT with four of the Project community co-ordinators representing three of the four participating communities. Graphic images were slightly modified and the terminology for activity areas and best practice characteristics made more user-friendly. Consensus was reached on the final GFPT with five food system domains and 28 activity areas (Fig. 1), with 120 associated best practice characteristics (Brimblecombe et al., 2014).
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Fig. 1. The final version of the Good Food Planning Tool (GFPT) with the five domains and 28 activity areas.
4. Discussion This study demonstrates that the application of the GFPT developed from a combination of best available evidence and expert knowledge was able to engage a wide range of stakeholders including Indigenous community residents in collectively assessing their local food system and in considering actions to improve food security in four contextually different remote Indigenous communities. From the perspective of Indigenous and non-Indigenous experts we defined the domains and activity areas that best represented the food systems of these four communities. The activity areas identified by community representatives were consistent with best available evidence and other expert opinion, although different terminology was used. The GFPT shares characteristics of other system assessment tools and frameworks (Wood and McDowell, 2009; Bailie et al., 2007; McDonald et al., 2013; Swinburn et al., 1999; Environments for Health, 2001). A key feature of the GFPT is that it was co-built with the input of a large group of stakeholders and comprises predefined domains, activity areas and best practice characteristics. The major difference between the GFPT and the system assessment tool (Bailie et al., 2007) and the healthy communities assessment tool (McDonald et al., 2013) (both specific to Indigenous Australian remote communities) is the focus of the GFPT on the food system with the aim of supporting food security, assisted by use of graphics and the ripple scoring tool. Although not directly obvious, the structure of the GFPT with its settingsbased domains is similar to the ANGELO framework (Swinburn et al., 1999; Simmons et al., 2009).
Similar to the settings-based approach to health promotion endorsed by the World Health Organization in the early 2000s (Paton et al., 2005; WHO, 2002), stakeholders in the context of this study preferred food system activities to be grouped by the whole setting (such as ‘food businesses’ or ‘community and services’) rather than by the separate socio-cultural, physical, economic, political and natural aspects of the environment. As a result of this, the GFPT focuses the attention of stakeholders not solely on introducing new strategies and initiatives, but on the state of current activity and where practices can be improved within services. Substantial improvement could occur through the different sectors and organisations in Indigenous Australian remote communities being supported to reflect on and improve practice within their own service/setting, as many (but not all) of the pathways for food security improvement operate at and are governed at the community level. When using the GFPT with the food interest groups in the four study communities, the pre-defined activity areas and best practice characteristics set the scenario for discussion of the whole local food system, rather than part of it, and focussed the discussion. A benefit of considering the whole local food system through use of the GFPT resulted in the identification of community actions to support local food security in both the short and long-term. Time constraints however at the annual planning meetings (which occurred over 2 half days each of 3 to 4 h duration) hindered the completion of action plans in some instances. Failing to produce a detailed and comprehensive course of action may cause collaborative efforts to focus on easier and less significant activities (that may not help achieve outcomes), rather than focusing on actions that
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could make more significant changes to system function (Kreuter et al., 2000). Any action planning process that involves problem solving, consensus building, and allocation of tasks can be complex and time intensive (Kreuter et al., 2000). To make most effective use of the limited time that stakeholders have available for planning activities, we therefore recommend that completion of action plans be undertaken concurrently with the food system appraisal when using the GFPT. Alternatively, stakeholders could be requested to commit extra time to the annual planning meeting, and/or commit to extra meetings to complete planning, or meet within their own organisation/service agency to bed down plans. A more gradual introduction to use of the GFPT in the Indigenous Australian remote community context could be to focus on one domain of the food system, such as food businesses, rather than the whole food system. This should allow time to develop a more detailed action plan in a specific priority domain, with buy-in from relevant stakeholders. It may also limit potential for a sense of being overwhelmed – and consequent inertia – that might arise when stakeholders try to address the whole food system at the one time. Additional domains of the food system can then be considered as stakeholders build their understanding of the food system, their capacity to plan together and confidence that outcomes can be achieved. In the Indigenous Australian remote community context, services are mostly delivered and managed in a siloed fashion through different sectors. Historically, there have been few attempts for co-ordination across sectors. Where attempts of service co-ordination are in place, through structures such as interagency groups, these in many communities include mostly non-Aboriginal service providers who head the various services within the community. Further, informal linkages that exist between agencies are often short-lived due to the high turnover of non-Aboriginal people in management or service provision positions. This high turnover of staff and pressure to deliver long-term outcomes in the short-term, often results in imposed quick-fix and single issue solutions and little time invested in building relationships across sectors through planning, reflection and evaluation, and in building community resident’s capacity in these areas (Sacks et al., 2008; Cargo et al., 2011). This minimises opportunity for collective learning on how different parts of the system respond to intervention and where the leverage points are for improvement. This study has shown that the GFPT and its facilitated application can bring different community voices together, and for stakeholders to learn from each other’s experiences. The GFPT therefore offers a process to enable change through specifically facilitating dialogue and interaction between the range of stakeholders involved in food systems, and through harnessing the unique assets and capacities of local communities; thus helping to ensure relevant responses to identified issues. The GFPT includes many of the environmental influences on household food security identified by Gorton et al. through a comprehensive international literature review (Gorton et al., 2010). The specification of domains, activity areas and best practice characteristics which characterise the GFPT also drew on the literature, including the national strategic and action plan for Aboriginal Australians and Torres Strait Islanders (SIGNAL, 2000) and other relevant policy statements and food service and food delivery guidelines. This Project now demonstrates how use of the GFPT by local policy makers, service providers and communities has the potential to translate these national strategic plans and policies into actions that are suited to the contexts and environments of different local community settings. The GFPT was designed for use in Aboriginal Australian remote communities. The tool could be adapted to capture the characteristics of food systems beyond the intended context with the input of relevant stakeholders using a methodology similar to that reported in this paper.
Further research is required in the application of the GFPT over time to further elucidate and define the important levers to effect change within the local food system. From a ‘systems thinking’ perspective, these levers are likely to relate to the mechanisms that connect and communicate with the different parts of a system and provide feedback to the whole system (WHO, 2009; Malhi et al., 2009). A further development of the tool could also be to identify the existing policy levers and policy opportunities in each sector of the food system and to highlight these (Sacks et al., 2008; Good et al., 2010). For example, local governments operating in Indigenous Australian remote communities have traditionally been involved in food and nutrition related activities including food safety regulation, land use for agriculture, community food services and monitoring of food retail premises (Yeatman, 2009). Sharpening of policy levers in these areas to include food security objectives may help in achieving food system improvements. Other tools that objectively measure aspects of food environments could also be considered for use alongside the GFPT to further inform stakeholder judgement and opinion (Kelly et al., 2011; McKinnon et al., 2009; Pomerleau et al., 2013; Glanz et al., 2007; NEAT, 2014). Further research is also required on the outcomes of the GFPT on local food system quality in the long-term and the extent to which this is associated with positive outcomes such as improvement in community safety, health risk factors, and diet-related diseases. The ripple scoring system used here to assess the performance of the local food system is based on the collective view of stakeholders in relation to how they perceive the quality of their food system. Research is warranted to test the inter-rater reliability and reliability of the ripple scoring system used with the GFPT over time within a community particularly with the high turnover of service providers and practitioners that occurs in Indigenous Australian remote communities. The key purpose of the GFPT however is not for quantification of the performance of the food system but to facilitate dialogue and new perspectives between stakeholders and depict the community vision of a performing food system and assist in developing action plans.
5. Conclusion The GFPT and its process of application supports an approach to food system planning that recognises the importance of engaging local stakeholders in developing plans that are acceptable and appropriate to the needs of a community. The harnessing of local knowledge, skills and experience and building a sense of collective sector responsibility for food security are important strategies in improving health and well-being in remote Indigenous communities. Ultimately, the outcome sought is to improve local food environments, local food security, and community, household and individual health and well-being. Improvements in relation to complex system issues such as food security are the result of many small incremental steps in building on existing initatives, reflecting on progress and learning from others. We believe the GFPT with support for its facilitated application is one more contribution towards the improvement so urgently needed.
Sources of support The study was funded through the National Health and Medical Research Council (545207). Julie Brimblecombe was supported by a NHMRC Public Health Fellowship, ID 545253 and is supported by a Future Leader Fellowship (Award ID: 100085) from the National Heart
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Foundation of Australia. Ross Bailie is supported by an ARC Future Fellowship (#FT100100087).
Acknowledgments We thank the four communities who participated in the larger GFS study and all personnel who contributed to the development of the GFPT. We acknowledge the invaluable contribution of the community coordinators, Elaine Maypilama, Jacob Spencer, Frank Nadjalaburrnburrn, Cheryl Nadjalaburrnburrn, Harold Bowen and Tania Deemal. A special thanks also to the other members of the GFS Project Management Committee – Megan Ferguson, Vivienne Hobson and Clare Brown. References ABS, 2001. Information paper: ABS views on remoteness. ABS Cat. no. 1244.0. Australian Bureau of Statistics, Canberra. ABS, 2010. Population characteristics of Aboriginal and Torres Strait Islander Australians. ABS Cat. no. 4713.0. Australian Bureau of Statistics, Canberra. ABS, 2011. Australian standard geographical classification (ASGC). ABS Cat. no. 1216.0. Australian Bureau of Statistics, Canberra. ABS, 2013.Census of Population and Housing: Socio-Economic Indexes for Areas (SEIFA). ABS Cat. no. 2033.0.55.001. Australian Bureau of Statistics, Canberra. AIHW, 2011. The Health and Welfare of Australia’s Aboriginal and Torres Strait Islander people. An Overview. Cat no: IHW 42. Australian Institute of Health and Welfare, Canberra. Bailie, R., Si, D., Dowden, M., O’Donoghue, L., Connors, C., Robinson, G., et al., 2007. Improving organisational systems for diabetes care in Australian Indigenous communities. BMC Health Serv. Res. 7, 67. Bailie, R., Matthews, V., Brands, J., Schierhout, G., 2013. A systems-based partnership learning model for strengthening primary healthcare. Implement. Sci. 8, 143. Bailie, R.S., Si, D., O’Donoghue, L., Dowden, M., 2007. Indigenous health: effective and sustainable health services through continuous quality improvement. Med. J. Aust. 186 (10), 525–527. Black A., 2007. Evidence of Effective Interventions to Improve the Social and Environmental Factors Impacting on Health: Informing the Development of Indigenous Community Agreements. Office for Aboriginal and Torres Strait Islander Health, Australian Government Department of Health and Ageing, Canberra. Black, A.P., Vally, H., Morris, P.S., Daniel, M., Esterman, A.J., Smith, F.E., et al., 2013a. Health outcomes of a subsidised fruit and vegetable program for Aboriginal children in northern New South Wales. Med. J. Aust. 199 (1), 46–50. Black, A.P., Vally, H., Morris, P., Daniel, M., Esterman, A., Karschimkus, C.S., et al., 2013b. Nutritional impacts of a fruit and vegetable subsidy programme for disadvantaged Australian Aboriginal children. Br. J. Nutr. 110 (12), 2309–2317. Brimblecombe J., van den Boogaard C., Liberato S.C., Brown J., Wood B., Barnes A., et al., 2014. The Good Food Planning Tool Darwin 2014. Available from: 〈http:// www.menzies.edu.au/page/Resources/Good_food_planning_tool/〉 [cited 2014]. Brimblecombe, J., Maypilama, E., Colles, S., Scarlett, M., Dhurrkay, J.G., Ritchie, J., et al., 2014. Factors influencing food choice in an Australian Aboriginal community. Q. Health Res. 24 (3), 387–400. Brimblecombe, J.K., Ferguson, M.M., Liberato, S.C., O’Dea, K., 2013. Characteristics of the community-level diet of Aboriginal people in remote northern Australia. Med. J. Aust. 198 (7), 380–384. Brimblecombe, J., van den Boogaard, C., Brown, J., Ritchie, J., Bailie, R., Coveney, J., Liberato, S.C., 2014. From targets to ripples: tracing the process of developing a community capacity appraisal tool with remote Australian Indigenous communities to tackle food security. BMC Public Health 14, 914. Bushe, G., Marshak, R., 2009. Revisioning organisational development: diagnostic and dialogic premises and patterns of practice. J. Appl. Behav. Sci. 45 (3), 348–368. Cargo, M., Marks, E., Brimblecombe, J., Scarlett, M., Maypilama, E., Dhurrkay, J.G., et al., 2011. Integrating an ecological approach into an Aboriginal communitybased chronic disease prevention program: a longitudinal process evaluation. BMC Public Health 11, 299. Caspi, C.E., Sorensen, G., Subramanian, S.V., Kawachi, I., 2012. The local food environment and diet: a systematic review. Health Place 18 (5), 1172–1187. Department for International Development (DFID), 2013. Sustainable Livelihoods Guidance Sheets. wwwdfidgovuk/ [Internet]. Available from: 〈http://www.efls. ca/webresources/DFID_Sustainable_livelihoods_guidance_sheet.pdf〉. Donelly, J., 2010. Maximising participation in international community-level project evaluation: a strength-based approach. Eval. J. Australas. 10 (1), 43–50. Edvardsson, K., Ivarsson, A., Garvare, R., Eurenius, E., Lindkvist, M., Mogren, I., et al., 2012. Improving child health promotion practices in multiple sectors—outcomes of the Swedish Salut Programme. BMC Public Health 12, 920. State Government Victoria, 2001. Environments for Health, Promoting Health and Wellbeing through Built, Social, Economic and Natural Environments: Municipal
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Public Health Planning Framework. State Government of Victoria, Department of Human Services, 2001. Giskes, K., Kamphuis, C.B., van Lenthe, F.J., Kremers, S., Droomers, M., Brug, J., 2007. A systematic review of associations between environmental factors, energy and fat intakes among adults: is there evidence for environments that encourage obesogenic dietary intakes? Public Health Nutr. 10 (10), 1005–1017. Giskes, K., van Lenthe, F., Avendano-Pabon, M., Brug, J., 2011. A systematic review of environmental factors and obesogenic dietary intakes among adults: are we getting closer to understanding obesogenic environments? Obes. Rev. 12 (5), e95–e106. Glanz, K., Yaroch, A.L., 2004. Strategies for increasing fruit and vegetable intake in grocery stores and communities: policy, pricing, and environmental change. Prev. Med. 39 (Suppl. 2), S75–S80. Glanz, K., Sallis, J.F., Saelens, B.E., Frank, L.D., 2007. Nutrition Environment Measures Survey in stores (NEMS-S): development and evaluation. Am. J. Prev. Med. 32 (4), 282–289. Good, E., Hammond, M., Martin, C., Burns, C., Groos, A., 2010. An audit of local government planning tools for their potential use in addressing community food and nutrition issues. Health Promot. J. Austr. 21 (1), 5–11. Gorton, D., Bullen, C.R., Mhurchu, C.N., 2010. Environmental influences on food security in high-income countries. Nutr. Rev. 68 (1), 1–29. Holsten, J.E., 2009. Obesity and the community food environment: a systematic review. Public Health Nutr. 12 (3), 397–405. Jayakaran R., 2002. The Ten Seed Technique. World Vision International, People’s Republic of China. Kelly, B., Flood, V.M., Yeatman, H., 2011. Measuring local food environments: an overview of available methods and measures. Health Place 17 (6), 1284–1293. Kreuter, M.W., Lezin, N.A., Young, L.A., 2000. Evaluating community-based collaborative mechanisms: implications for practitioners. Health Promot. Pract. 1, 1. Lee, A., 1996. The transition of Australian Aboriginal diet and nutritional health. World Rev. Nutr. Diet. 79, 1–52. Lee, A.J., Bailey, A.P., Yarmirr, D., O’Dea, K., Mathews, J.D., 1994. Survival tucker: improved diet and health indicators in an Aboriginal community. Aust. J. Public Health. 18 (3), 277–285. Malhi, L., Karanfil, O., Merth, T., Acheson, M., Palmer, A., Finegood, D.T., 2009. Places to intervene to make complex food systems more healthy, green, fair, and affordable. J. Hunger Environ. Nutr. 4 (3-4), 466–476. McDonald, E.L., Bailie, R., Michel, T., 2013. Development and trialling of a tool to support a systems approach to improve social determinants of health in rural and remote Australian communities: the healthy community assessment tool. Int. J. Equity Health 12, 15. McKinnon, R.A., Reedy, J., Morrissette, M.A., Lytle, L.A., Yaroch, A.L., 2009. Measures of the food environment: a compilation of the literature, 1990–2007. Am. J. Prev. Med. 36 (4 Suppl.), S124–S133. Nutrition Environment Assessment Tool (NEAT), 2014. Michigan Healthy Communities Initiative; 2014. Available from 〈http://mihealthtools.org/neat/〉 [updated 4/4/2014]. Paton, K., Sengupta, S., Hassan, L., 2005. Settings, systems and organization development: the healthy living and working model. Health Promot. Int. 20 (1), 81–89. Pomerleau, J., Knai, C., Foster, C., Rutter, H., Darmon, N., Derflerova Brazdova, Z., et al., 2013. Measuring the food and built environments in urban centres: reliability and validity of the EURO-PREVOB Community Questionnaire. Public Health 127 (3), 259–267. Rowley, K.G., Daniel, M., Skinner, K., Skinner, M., White, G.A., O’Dea, K., 2000. Effectiveness of a community-directed ‘healthy lifestyle’ program in a remote Australian Aboriginal community. Aust. N. Z. J. Public Health 24 (2), 136–144. SIGNAL, 2000. National Aboriginal and Torres Strait Islander Nutrition Strategy and Action Plan. National Aboriginal and Torres Strait Islander Nutrition Working Party, 2000. Sacks, G., Swinburn, B.A., Lawrence, M.A., 2008. A systematic policy approach to changing the food system and physical activity environments to prevent obesity. Aust. N. Z. Health Policy 5, 13. Signal, L.N., Walton, M.D., Ni Mhurchu, C., Maddison, R., Bowers, S.G., Carter, K.N., et al., 2013. Tackling ‘wicked’ health promotion problems: a New Zealand case study. Health Promot. Int. 28 (1), 84–94. Simmons, A., Mavoa, H.M., Bell, A.C., Court, D., Schaaf, D., Schultz, J., et al., 2009. Creating community action plans for obesity prevention using the ANGELO (Analysis Grid for Elements Linked to Obesity) Framework. Health Promot. Int. 24 (4), 311–324. Swinburn, B., Egger, G., 2002. Preventive strategies against weight gain and obesity an official journal of the International Association for the Study of Obesity. Obes. Rev. 3 (4), 289–301. Swinburn, B., Egger, G., Raza, F., 1999. Dissecting obesogenic environments: the development and application of a framework for identifying and prioritizing environmental interventions for obesity. Prev.Med. 29 (6 Pt 1), 563–570. Swinburn, B., Gill, T., Kumanyika, S., 2005. Obesity prevention: a proposed framework for translating evidence into action. Obes. Rev. 6 (1), 23–33. Tansey, G., Worsley, T., 1995. The Food System: A Guide. Earthscan, Milton, Oxfordshire p. 253. Vos, T., Barker, B., Begg, S., Stanley, L., Lopez, A.D., 2009. Burden of disease and injury in Aboriginal and Torres Strait Islander Peoples: the Indigenous health gap. Int. J. Epidemiol. 38 (2), 470–477. WHO, 2002. The World Health Report 2002: Reducing Risks, Promoting Healthy Life. World Health Organisation, Geneva.
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Contents lists available at ScienceDirect
Health & Place journal homepage: www.elsevier.com/locate/healthplace
Development of the good food planning tool: A food system approach to food security in indigenous Australian remote communities Julie Brimblecombe a,n, Christel van den Boogaard a, Beverley Wood a, Selma C Liberato a, Jacqui Brown a, Adam Barnes e, Alison Rogers b, John Coveney a,c, Jan Ritchie a,d, Ross Bailie a a
Menzies School of Health Research, Darwin, NT, Australia The Fred Hollows Foundation, Indigenous Australia Program, Darwin, NT, Australia c Flinders University, Adelaide, SA, Australia d University of New South Wales, Sydney, NSW, Australia e Northern Territory Department of Health, Darwin, NT, Australia b
art ic l e i nf o
a b s t r a c t
Article history: Received 4 September 2014 Received in revised form 3 February 2015 Accepted 11 March 2015
Few frameworks exist to assist food system planning, especially for Indigenous Australian remote communities. We developed a Good Food Planning Tool to support stakeholders to collectively plan and take action for local food system improvement. Development occurred over a four-year period through an evolving four phase participatory process that included literature review, several meetings with representatives of various organisations and communities and application of the Tool with multi-sector groups in each of four Indigenous Australian remote communities. A diverse range of 148 stakeholders, 78 of whom were Indigenous, had input to its development. Five food system domains: (i) Leadership and partnerships; (ii) Traditional food and local food production; (iii) Food businesses; (iv) Buildings, public places and transport; (v) Community and services and 28 activity areas form the framework of the Tool. The Good Food Planning Tool provides a useful framework to facilitate collective appraisal of the food system and to identify opportunities for food system improvement in Indigenous Australian remote communities, with potential for adaptation for wider application. & 2015 Elsevier Ltd. All rights reserved.
Keywords: Food systems Food security Indigenous Australia Food system assessment Multi-sectoral
1. Introduction Local food systems for Indigenous Australians have changed significantly in recent history (Lee, 1996). Indigenous Australian remote communities now depend largely on store purchased foods and to a lesser extent on traditionally collected foods and locally produced foods (Brimblecombe et al., 2013). Change in local food systems has come at a great cost to the health of communities and individuals, with food insecurity (AIHW, 2011) and dietrelated conditions (such as overweight, obesity, cardiovascular disease, type 2 diabetes) now major contributors to the serious health gap between Indigenous and non-Indigenous Australians (Vos et al., 2009). It is well accepted that reliance on individual level approaches and/or a focus on mechanisms within a single area of the food system are not enough to improve food security and stem burgeoning diet related conditions; major changes to the food environment are necessary (Swinburn and Egger, 2002). This
n Corresponding author at: Menzies School of Health Research, John Mathews Building (58), Royal Darwin Hospital, PO Box 41096, Casuarina, NT 0811, Australia. Tel.: þ 61 8 89228577; fax: þ 61 8 89275187. E-mail address: [email protected] (J. Brimblecombe).
http://dx.doi.org/10.1016/j.healthplace.2015.03.006 1353-8292/& 2015 Elsevier Ltd. All rights reserved.
requires taking a holistic view to consider the multiple areas of the food system and to change the relevant societal, economic and physical drivers in a direction that is health promoting (Signal et al., 2013). The ways to do this are not straightforward as food environments are complex and dynamic (Swinburn et al., 2005). Evidence-based strategies for addressing the burden of dietrelated conditions are also limited (Swinburn et al., 2005; Giskes et al., 2007, 2011; Holsten, 2009; Caspi et al., 2012). Decisionmaking processes that combine best available evidence and local knowledge to develop a course of action and to create new perspectives and narratives that impact on how people think and act are receiving increasing attention (Swinburn et al., 2005; Bushe and Marshak, 2009; Edvardsson et al., 2012). These approaches are believed to have the greatest chance of responding to the changing nature of the food environment and in developing strategies that are comprehensive, contextually relevant and suited to the community of concern (Swinburn and Egger, 2002). In the context of Indigenous Australian remote communities, two innovative system approaches to planning that have potential application to local food systems have been used to improve quality of primary health care and essential service delivery (Bailie et al., 2007; McDonald et al., 2013). These draw on the principles of quality improvement and participatory learning
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(Bailie et al., 2013; WHO, 2007) and use a systems assessment tool to support stakeholders to collectively appraise practice against a pre-defined set of best practice goals (Bailie et al., 2007). From this, an action plan is developed and data on practice and outcome measures are collected to provide feedback on performance. A cornerstone of these system approaches is the focus on achieving quality improvement through a structured ongoing cycle of participatory assessment, planning and action, to achieve stepby-step incremental improvement. Through this process of discussion and analysis stakeholders incrementally build their knowledge of the nature of the system and how it behaves. As far as we know there have been no initiatives in the Indigenous Australian remote community context that have sought to engage a group of stakeholders at the local level in a systematic and ongoing process of decision-making for food system improvement. Yet the few community-based interventions in this context shown to positively impact on diet-related conditions point towards the importance of addressing multiple areas of the food system (Lee et al., 1994; Rowley et al., 2000; Black et al., 2013a, 2013b), and involving local stakeholders and community leaders in planning, implementation and evaluation activities (Black, 2007). The unique history, governance structures and other characteristics of the food environments of Indigenous Australian remote communities need to be considered in food system decisionmaking processes as these can offer both opportunities and challenges. Different geographical locations exhibit unique characteristics that necessitate special consideration. There are over 160 discrete communities in remote Indigenous Australia with populations of more than 100 people that are located over vast tracts of the nation and are geographically isolated from larger urban centres (ABS, 2010). These communities have all experienced a recent history of European invasion, colonisation and oppression and continue the struggle of retaining their culture and rights in a wider society where a western worldview dominates. Communities have retained structures of Indigenous leadership that co-exist with non-indigenous governance structures. Further important characteristics are that most communities are small in population size and yet have a large ratio of and high turnover of non-Indigenous service providers (such as medical professionals, public health nutritionists, aged-care managers, horticulturalists, store managers) per capita; and, also, that food hunting and gathering plays an important economic, dietary and cultural role in most communities. The few food environment related assessment tools (Wood and McDowell, 2009; Swinburn
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et al., 1999; DFID, 2013; Tansey and Worsley, 1995; Kelly et al., 2011; McKinnon et al., 2009; Pomerleau et al., 2013; Glanz et al., 2007; NEAT, 2014) that exist do not capture all elements of this unique environment nor have they been purposefully developed as part of an integrated quality improvement process. In response to a heightened interest to redress food security in Indigenous remote communities by the Australian government and community leaders seeking opportunity to ‘have a say’ in the development and implementation of food security initiatives, we aimed to develop a tool structure and implementation approach that would enable the engagement of community people and other stakeholders to identify gaps, barriers and opportunities for improvement of the food system, as part of an integrated quality improvement process. The development of the Good Food Planning Tool (GFPT) occurred as part of the Good Food Systems: Good Food for All Project (GFS Project)—a five-year case study (2009– 2013) that aimed to assist stakeholders, including Indigenous community residents, to collectively identify food system challenges and opportunities to improve food security (i.e., food availability, access and utilisation) over time. This article describes the development of the GFPT and its implementation in four communities.
2. Methods 2.1. Good food planning tool development: Evolving participatory process The GFPT evolved through a four phase participatory process as shown in Table 1. It was informed by multiple sources of data collected through literature review, expert review of an early version of the GFPT, four stakeholder meetings with Indigenous and non-Indigenous stakeholders (for test of relevance and validity), application with food interest groups in each of the four Indigenous communities as part of the GFS project (for test of application), and experience gained by all. 2.1.1. Study setting Two of the Indigenous Australian remote communities that participated in the GFS project and whose members contributed to the development of the GFPT were situated on the North Australian coast, another was inland from the coast and a fourth was in the Central Australian desert. The communities varied in size
Table 1 Outline of the GFPT development phases and associated dates, activity and aim. Phase
Date
Phase 1: April-Sept 2009 Development
Activity
Aim
Literature review Expert review n¼ 22 (2 Aboriginal participants)
Determine food system domains, activity areas, corresponding best practice characteristics and application process Check the activity areas and corresponding best practices with food delivery, food retail and food policy experts Check all aspects of the tool Inductively identify activity areas and corresponding best practice characteristics for each food system domain Compare and contrast these against GFPT Determine and test process for Tool application
Phase 2: Test of 29th Sept 2009 Meeting 1a b n¼ 13 (3 Aboriginal participants) 16th-17th Feb 2010 Meeting 2ab n¼ 27 (15 Aboriginal participants) relevance
Phase 3: Test of 2nd-4th Nov 2011 validity
Phase 4: Refinement
Meeting 3a
b
n¼ 20 (14 Aboriginal participants)
Annually 2010-2013 Annual planning meetings with community-based food-interest groups in each of the four communitiesa n¼ 26-42 Sept 2012 Data review
Meeting 4a n ¼7 (4 Aboriginal community coordinators) a b
Review all data for any emerging and/or divergent food system domains, activity areas or best practice characteristics Check terminology and graphics
Participant numbers include the facilitators and/or members of the research team who also provided expert content knowledge. These meetings were all urban-based in contrast to the annual planning meetings that were community-based and community specific.
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(250 to over 2000 residents), were classified as very remote (ABS, 2001, 2011) (accessible by long distance road travel, by small aircraft or boat), and socio-economically disadvantaged (ABS, 2013). The four communities were of Aboriginal heritage and diverse in cultural practices. Multiple languages were spoken in each community and English was the main language in only one community. All four communities were serviced by a local government authority and had a community owned store, a school, arts community, health centre, employment program and other services such as aged-care, sports and recreation and child-care. Three of the four communities had one or more additional food outlets (for example—fast food outlet, club, convenience store, butchery). Food delivery to the communities was by long distance road (weekly or fortnightly) or by weekly barge and aircraft. Fresh goods were usually delivered by aircraft to one community in the wet season ( October to May). Extreme weather conditions periodically disrupted the supply of food to all communities. 2.1.2. Stakeholders A diverse range of Indigenous and non-Indigenous stakeholders with different roles in the food system were invited to have input to the development of the GFPT through review of an early version of the GFPT and/or participation in a series of four urban-based meetings. These stakeholders included residents from the four GFS study communities and other stakeholders also with expertise in aspects of food systems. 2.1.3. Community multi-sector groups (the food-interest groups) In each community, the GFS Project supported stakeholders with an interest in the community food system to participate in annual planning meetings (of 2 half days) to appraise their food system and prioritise a set of actions (for commitment to implementation) using the GFPT (or developing versions). Four annual planning meetings took place over the course of the GFS Project in two communities, with three such meetings in the third community and one only in the remaining site. Participation was voluntary and open to any community member (both Indigenous and non-Indigenous) or external stakeholder who had an interest in, or who might impact on the local food system. A member of the research team (Project facilitator) and a local resident Aboriginal community co-ordinator (employed by the Project) facilitated these meetings. The GFPT was progressively refined over several versions during the course of the GFS Project. 2.1.3.1. Ethics. Ethics approval for all aspects of the Good Food Systems: Good Food for All Project was attained from the Human Research Ethics Committee (HREC) of the Northern Territory Department of Health and Menzies School of Health Research (ref. HREC 09/07), Cairns and Hinterland Health Service District Ethics Committee (ref. HREC/10/QCH/71-678) and the Central Australian HREC (ref 2009.02.02). Signed partnership agreements were negotiated with participating organisations and communities.
3. Results 3.1. Phase 1. Development of the first versions of the GFPT 3.1.1. Literature review We drew from existing system tools (Bailie et al., 2007, 2013; McDonald et al., 2013) and food environment related assessment tools (Wood and McDowell, 2009; Swinburn et al., 1999; DFID, 2013) to determine tool structure and content. The structure selected for the GFPT was that of the systems assessment tool successfully used in the primary health care setting in the Indigenous Australian
remote community context (Bailie et al., 2007). System domains (such as ‘food businesses’), activity areas for each domain (such as the placement and promotion of food in the ‘food businesses’ domain) and best practice characteristics for each activity area (such as for placement—“Food is placed in a way that encourages healthy food choices” and for promotion—“Healthy food is promoted in the store”) were then identified and continually refined over the course of Tool development. In doing this, the first aim in development of the GFPT was to systematically identify the range of activities in the Indigenous Australian remote community context that related to each of the dimensions of food security (food availability, access and utilisation) for each function of a food system (Tansey and Worsley, 1995) (food collection/growing to waste disposal and recycling) and in each area of the environment (socio-cultural, physical, economic and political and natural) (Wood and McDowell, 2009; Swinburn et al., 1999; Sacks et al., 2008; Environments for Health, 2001). This occurred first through a scan of published and grey literature to identify: (i) the factors considered to influence food security in the Indigenous Australian remote community context (Brimblecombe et al., 2014; Gorton et al., 2010); (ii) related food policies, programs, services and guidelines; and, (iii) practices considered to influence the consumer food environment (Glanz and Yaroch, 2004) and traditional food access and use (Woodley et al., 2009).
3.1.2. Expert review We then elicited the views of 22 expert stakeholders, representing the remote community food retail industry (7), food wholesalers (1), academia (3), national nutrition policy (1), Australian and territory government (5) and non-government organisations (5), through written and oral feedback, on both the proposed structure and content of the GFPT and its application. The following recommendations were made: (1) Include all areas of the local food system that relate to food security including traditional food and local food production; (2) In its application, identify actions based on what is in the best interest of the community, community capacity to address the problems, and local leadership capacity; (3) Link the food system to health indicators; (4) Include evidence-based scenarios of how to achieve improvement in the different activity areas and show where linkages within the system occur; (5) Keep the GFPT brief, comprehensive and non-prescriptive, with the use of plain English and graphics; (6) Ensure strong community representation in community level multi-sector food interest groups and address issues as determined by community decision; (7) Support food system improvement from the angle of ‘goalsetting’ and establish a shared vision for the food system with the group of stakeholders. As a result of this feedback, the scope of the GFPT was broadened from an initial focus on the community store (as the primary source of food in a remote community) and its community-wide linkages, to include all areas of activity relating to the different food system functions including the production and procurement of local and traditional foods.
3.2. Phase 2. Test of relevance for the GFPT Thirteen food retail and policy experts participated in a first meeting to identify and reach consensus on activity areas and best practice characteristics for the food system functions relating to food delivery, food-related policy and food retailing (Table 1).
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These were then cross-checked against the GFPT and modifications made accordingly. In the second meeting, 27 stakeholders including 16 residents of the four GFS communities and 11 people with expertise in health promotion, public health nutrition, food security policy, food systems, store governance and retail practice reviewed each domain of the GFPT alongside the activity areas and best practice characteristics and provided comment on relevance to the Indigenous Australian remote community context, clarity of terminology and graphic images, and gaps. Participants preferred food system activities to be grouped by the setting or area of responsibility rather than by the socio-cultural, physical, economic, political and natural aspects of the environment. For example, activities relating to food businesses such as the availability of a full range of healthy food and placement of foods to encourage healthy food purchasing, were then grouped within a domain called “food businesses” rather than in a domain called “physical environment”.
3.3. Phase 3. Test of validity for the GFPT Twenty people representing the four participating communities (and Good Food Systems Project facilitators) with most being Aboriginal then participated in a third meeting to test if the domain and activity areas of the evolving GFPT corresponded with areas
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identified by Indigenous community representatives as relevant to their local food systems. To begin, each community group of three to six people expressed their view of their local food system through use of drawings and existing photos and presented this view to the whole group. The significance of traditional food in the local food system was apparent and depicted separately to the settings responsible for different aspects of the food system (such as the store, the local government services, the school, and the health centre). The whole group was then invited to inductively identify a set of activity areas perceived as important to food security for each of the five food system domains included in the evolving GFPT. The question asked to participants for each domain was: “what activity would you see in your community if this area of the food system was really strong?” The community derived activity areas are shown in Table 2. They were broadly consistent with the activity areas and the best practice characteristics identified through the previous tool development phases although different terminology was used.
3.3.1. Application of GFPT with community-based food-interest groups In each of the four participating communities, 26–42 different Indigenous and non-Indigenous stakeholders participated in at least one annual planning meeting over the GFS Project period (2009–2013) and used the GFPT. Through these meetings a facilitated process to support the collective use of the GFPT to
Table 2 Activity areas important to food security in several food system domains as identified by community representatives and the final GFPT. Food system domain
Activity areas (as identified by community representatives)
Activity areas (final GFPT)
Leadership and partnerships
Community needs assessment; strong voices in community; consulting with Elders Sharing of resources; working together and strong communication Elders participating in decision-making
Leadership Good linking and partnerships Community plans and policies/ community ownership Local workforce investment
Leadership training; employment and capacity building; skill development in home maintenance; employment of Indigenous Essential Service Officers Sector support from local government authority Knowledge translation from elders; caring for elders, so they can pass on knowledge; information collected and reported on nutritional status of community Traditional foods and Care and management of country; conservation practices in place; laws and regulations that local food production protect traditional food and Indigenous land and water rights Access to traditional food supported, e.g., hunting permits for community people easily accessed Teaching in two ways in schools and on country; programs in place to develop knowledge and skills of youth Local food production e.g., market gardens; banana farm Community and Community-wide promotion and support for healthy eating; parents role-modelling healthy services eating Development of cooking skills; access to meaningful nutrition information; schools teaching nutrition; school breakfast program in place; local media broadcasting health messages; support for festivals/ health fairs and culture week Nutrition programs for: young women, mothers and families of children with growth and development issues, and for people with diet-related conditions such as type 2 diabetes Community services promoting healthy eating Support for aged-care services Buildings, public places Adequate buildings to support healthy eating and transport Families working together for a healthy home; adequate housing and infrastructure; adequate household food storage and food preparation facilities; house owner taking responsibility for upkeep of home Adequate, good quality water supply; good and reliable power supply Frequent and adequate food delivery to community Food businesses Community leaders ensure that store is of a high standard Well supported staff; food safety training for staff Strong and functioning store committee; community support for store committee; compliance with workplace health and safety regulations; compliance with food safety practices; no dogs in store Adequate infrastructure (e.g., air-conditioning/ refrigeration) No out-of-date food in shops; healthy food available when shop opens; fresh food (such as milk and bread) available; healthy takeaway options available; budgeting and financial support available Pricing encourages healthy food purchases (e.g., mark down on healthy foods (fruit and veg and other foods)) Healthy food promoted (e.g., store shelf-talkers, posters, food signs, fruit bowl at counter)
Commitment to action Good information and feedback systems Care and management Traditional food promotion and use; Things you need to go hunting and collecting Passing on knowledge Local food production Community support Promotion activities and training
Health services support Food services Buildings and public places Homes
Safe drinking water and power Transport and food delivery Community support People in food businesses Policies and management support Places (buildings) Products
Prices Promotion and placement
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appraise the food system and develop a plan of action evolved (Box 1). Facilitated by the project community co-ordinators and/or project facilitator (JB, JBr, CB or AB), stakeholders in all four communities were collectively able to use the GFPT to assess their community local food system. They could score each food system activity area using the qualitative ripple scoring system developed through the GFS project (Brimblecombe JvdB et al., 2014) and shown in Box 2. This participatory and visual method of appraising domains and activities for our purposes was found to be more acceptable to participants than the original linear scoring scale of 0 to 11 based on the systems assessment tool used in the Indigenous Australian primary health care setting (Bailie et al., 2007). The best practice characteristics for each activity area helped facilitate
discussion on the strength of each activity area. Reasons given by the group of stakeholders for the scoring of each activity area were recorded, together with the discussions of challenges and opportunities for improvement and the long list of identified actions. Only in two communities did time permit prioritisation of actions. This then contributed to the development of an action plan (with time frame and responsibilities) to be used in subsequent review meetings as part of the quality improvement process.
Box 1–The steps used in facilitation of the GFPT to appraise the food system and develop a plan of action. More detail is available in the Good Food Planning Tool and guide for users (Brimblecombe et al., 2014). – Explain the structure of the GFPT and the appraisal process – For each food system domain, provide a verbal description of each activity area using the best practice characteristics as examples – Show the visual for the activity area being discussed, and ask the group to reflect and comment on how strongly they see the activity area performing in their community – After listening to and recording the group’s discussion, place the visual on one of five circles of a ripple diagram (where the outer circle represents very strong/fully developed and the inner circle, just developing) that seems to best represent people’s comments and ask if this matches with their perception; and then, – Manage the discussion until consensus is reached and write agreed discussion points on a sticky note to then also display on the ripple; – Record on a sticky note any actions or strategies to strengthen the area being discussed that arise in the discussion – Continue to discuss each activity area for each domain and record the appraisal process using a different ripple for each domain – Take a photo for future comparison with the next food system appraisal – Manage a discussion to further identify actions – Use a participatory tool such as the ten seed technique (Jayakaran, 2002) or pocket chart (Donelly, 2010) to prioritise actions and define a plan of action.
3.4. Phase 4. Refinement of the GFPT 3.4.1. Information review Three authors (JB, CB and SL) reviewed and cross-checked all data collected from the activities of the previous Phases (1–3) and from the food system appraisals and actions plans and/or list of actions developed through the GFS annual planning meetings to identify any emerging and/or divergent food system domains, activity areas or best practice characteristics and any other issues including interpretation. No emerging new themes or activity areas were identified. A number of inter-related activity areas were merged with more detail on the characteristics of best practice included.
Box 2 An example of the appraisal of the “food businesses” domain, by a community food-interest group; using the ripple scoring system. Based on a facilitated dialogue and consensus by the group, a picture card representing each activity area is placed on a circle of the ripple where the outer circle represents very strong/fully developed and the inner circle, just developing. This example shows that in this community, the group of stakeholders viewed practices relating to food price and community support for store business as areas that needed most strengthening in their community.
3.4.2. Community review The last step in achieving a set of domains, activity areas and best practice characteristics that reflected the food systems in the participating communities was to review the last version of the GFPT with four of the Project community co-ordinators representing three of the four participating communities. Graphic images were slightly modified and the terminology for activity areas and best practice characteristics made more user-friendly. Consensus was reached on the final GFPT with five food system domains and 28 activity areas (Fig. 1), with 120 associated best practice characteristics (Brimblecombe et al., 2014).
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Fig. 1. The final version of the Good Food Planning Tool (GFPT) with the five domains and 28 activity areas.
4. Discussion This study demonstrates that the application of the GFPT developed from a combination of best available evidence and expert knowledge was able to engage a wide range of stakeholders including Indigenous community residents in collectively assessing their local food system and in considering actions to improve food security in four contextually different remote Indigenous communities. From the perspective of Indigenous and non-Indigenous experts we defined the domains and activity areas that best represented the food systems of these four communities. The activity areas identified by community representatives were consistent with best available evidence and other expert opinion, although different terminology was used. The GFPT shares characteristics of other system assessment tools and frameworks (Wood and McDowell, 2009; Bailie et al., 2007; McDonald et al., 2013; Swinburn et al., 1999; Environments for Health, 2001). A key feature of the GFPT is that it was co-built with the input of a large group of stakeholders and comprises predefined domains, activity areas and best practice characteristics. The major difference between the GFPT and the system assessment tool (Bailie et al., 2007) and the healthy communities assessment tool (McDonald et al., 2013) (both specific to Indigenous Australian remote communities) is the focus of the GFPT on the food system with the aim of supporting food security, assisted by use of graphics and the ripple scoring tool. Although not directly obvious, the structure of the GFPT with its settingsbased domains is similar to the ANGELO framework (Swinburn et al., 1999; Simmons et al., 2009).
Similar to the settings-based approach to health promotion endorsed by the World Health Organization in the early 2000s (Paton et al., 2005; WHO, 2002), stakeholders in the context of this study preferred food system activities to be grouped by the whole setting (such as ‘food businesses’ or ‘community and services’) rather than by the separate socio-cultural, physical, economic, political and natural aspects of the environment. As a result of this, the GFPT focuses the attention of stakeholders not solely on introducing new strategies and initiatives, but on the state of current activity and where practices can be improved within services. Substantial improvement could occur through the different sectors and organisations in Indigenous Australian remote communities being supported to reflect on and improve practice within their own service/setting, as many (but not all) of the pathways for food security improvement operate at and are governed at the community level. When using the GFPT with the food interest groups in the four study communities, the pre-defined activity areas and best practice characteristics set the scenario for discussion of the whole local food system, rather than part of it, and focussed the discussion. A benefit of considering the whole local food system through use of the GFPT resulted in the identification of community actions to support local food security in both the short and long-term. Time constraints however at the annual planning meetings (which occurred over 2 half days each of 3 to 4 h duration) hindered the completion of action plans in some instances. Failing to produce a detailed and comprehensive course of action may cause collaborative efforts to focus on easier and less significant activities (that may not help achieve outcomes), rather than focusing on actions that
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could make more significant changes to system function (Kreuter et al., 2000). Any action planning process that involves problem solving, consensus building, and allocation of tasks can be complex and time intensive (Kreuter et al., 2000). To make most effective use of the limited time that stakeholders have available for planning activities, we therefore recommend that completion of action plans be undertaken concurrently with the food system appraisal when using the GFPT. Alternatively, stakeholders could be requested to commit extra time to the annual planning meeting, and/or commit to extra meetings to complete planning, or meet within their own organisation/service agency to bed down plans. A more gradual introduction to use of the GFPT in the Indigenous Australian remote community context could be to focus on one domain of the food system, such as food businesses, rather than the whole food system. This should allow time to develop a more detailed action plan in a specific priority domain, with buy-in from relevant stakeholders. It may also limit potential for a sense of being overwhelmed – and consequent inertia – that might arise when stakeholders try to address the whole food system at the one time. Additional domains of the food system can then be considered as stakeholders build their understanding of the food system, their capacity to plan together and confidence that outcomes can be achieved. In the Indigenous Australian remote community context, services are mostly delivered and managed in a siloed fashion through different sectors. Historically, there have been few attempts for co-ordination across sectors. Where attempts of service co-ordination are in place, through structures such as interagency groups, these in many communities include mostly non-Aboriginal service providers who head the various services within the community. Further, informal linkages that exist between agencies are often short-lived due to the high turnover of non-Aboriginal people in management or service provision positions. This high turnover of staff and pressure to deliver long-term outcomes in the short-term, often results in imposed quick-fix and single issue solutions and little time invested in building relationships across sectors through planning, reflection and evaluation, and in building community resident’s capacity in these areas (Sacks et al., 2008; Cargo et al., 2011). This minimises opportunity for collective learning on how different parts of the system respond to intervention and where the leverage points are for improvement. This study has shown that the GFPT and its facilitated application can bring different community voices together, and for stakeholders to learn from each other’s experiences. The GFPT therefore offers a process to enable change through specifically facilitating dialogue and interaction between the range of stakeholders involved in food systems, and through harnessing the unique assets and capacities of local communities; thus helping to ensure relevant responses to identified issues. The GFPT includes many of the environmental influences on household food security identified by Gorton et al. through a comprehensive international literature review (Gorton et al., 2010). The specification of domains, activity areas and best practice characteristics which characterise the GFPT also drew on the literature, including the national strategic and action plan for Aboriginal Australians and Torres Strait Islanders (SIGNAL, 2000) and other relevant policy statements and food service and food delivery guidelines. This Project now demonstrates how use of the GFPT by local policy makers, service providers and communities has the potential to translate these national strategic plans and policies into actions that are suited to the contexts and environments of different local community settings. The GFPT was designed for use in Aboriginal Australian remote communities. The tool could be adapted to capture the characteristics of food systems beyond the intended context with the input of relevant stakeholders using a methodology similar to that reported in this paper.
Further research is required in the application of the GFPT over time to further elucidate and define the important levers to effect change within the local food system. From a ‘systems thinking’ perspective, these levers are likely to relate to the mechanisms that connect and communicate with the different parts of a system and provide feedback to the whole system (WHO, 2009; Malhi et al., 2009). A further development of the tool could also be to identify the existing policy levers and policy opportunities in each sector of the food system and to highlight these (Sacks et al., 2008; Good et al., 2010). For example, local governments operating in Indigenous Australian remote communities have traditionally been involved in food and nutrition related activities including food safety regulation, land use for agriculture, community food services and monitoring of food retail premises (Yeatman, 2009). Sharpening of policy levers in these areas to include food security objectives may help in achieving food system improvements. Other tools that objectively measure aspects of food environments could also be considered for use alongside the GFPT to further inform stakeholder judgement and opinion (Kelly et al., 2011; McKinnon et al., 2009; Pomerleau et al., 2013; Glanz et al., 2007; NEAT, 2014). Further research is also required on the outcomes of the GFPT on local food system quality in the long-term and the extent to which this is associated with positive outcomes such as improvement in community safety, health risk factors, and diet-related diseases. The ripple scoring system used here to assess the performance of the local food system is based on the collective view of stakeholders in relation to how they perceive the quality of their food system. Research is warranted to test the inter-rater reliability and reliability of the ripple scoring system used with the GFPT over time within a community particularly with the high turnover of service providers and practitioners that occurs in Indigenous Australian remote communities. The key purpose of the GFPT however is not for quantification of the performance of the food system but to facilitate dialogue and new perspectives between stakeholders and depict the community vision of a performing food system and assist in developing action plans.
5. Conclusion The GFPT and its process of application supports an approach to food system planning that recognises the importance of engaging local stakeholders in developing plans that are acceptable and appropriate to the needs of a community. The harnessing of local knowledge, skills and experience and building a sense of collective sector responsibility for food security are important strategies in improving health and well-being in remote Indigenous communities. Ultimately, the outcome sought is to improve local food environments, local food security, and community, household and individual health and well-being. Improvements in relation to complex system issues such as food security are the result of many small incremental steps in building on existing initatives, reflecting on progress and learning from others. We believe the GFPT with support for its facilitated application is one more contribution towards the improvement so urgently needed.
Sources of support The study was funded through the National Health and Medical Research Council (545207). Julie Brimblecombe was supported by a NHMRC Public Health Fellowship, ID 545253 and is supported by a Future Leader Fellowship (Award ID: 100085) from the National Heart
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Foundation of Australia. Ross Bailie is supported by an ARC Future Fellowship (#FT100100087).
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