Table 5 Summary of research findings from included publications

Ashman (2016) [35]

Australia

Funding: NHMRC

University of Newcastle

27 women, 8 Indigenous (aged >17, gestation <25 weeks), median age 28. 8 regional outpatient settings (hospital, GP clinics, community organisations), New South Wales (NSW)

Aim: To use smartphones to take detailed assessments of dietary intake, and provide personalised online feedback, with dietician consultation.

Method: Quantitative evaluation study. The women collected image-based dietary records, completed 24-h food recalls and a food frequency questionnaire, as well as 3 online surveys.

12-week study of “Diet Bytes” and “SNaQ” methods. Smartphones used to record dietary intake and participants received a video with personalised advice comparing their intake to the Australian Guidelines, then phone contact with a nutritionist.

N = 17, 77% reported dietary changes as a result of feedback. Core food group consumption was reported separately for Indigenous women. Intake was close to recommendations for fruit and dairy but below for grains, cereals, vegetables and meat. All Indigenous women met recommendations for unsaturated spreads and oils.

Based on the personalised feedback, some ate more foods from core food groups, others consumed less sugary drinks or “junk” foods. Others changed cooking methods

Less than half the participants felt they had enough information about healthy eating at the time of enrolment.

The Diet Bytes method for nutrition assessment combined with the SNaQ tool for analysing nutritional content, with the provision of personally tailored feedback, may be a useful method for dietitians to assist women in optimising their food and nutrient intakes during pregnancy.

Bennett-Levy (2017) [36]

Australia

Funding:

Australian Federal Government

26 health professionals (21 Indigenous) in regional centres in northern NSW.

Aim: To identify the barriers and enablers of e-mental health (e-MH) uptake amongst mainly Aboriginal and Torres Strait Islander health professionals.

Method: Qualitative evaluation study. Trainers provided written reports and were interviewed. These data sources were analysed thematically.

A 3- or 2-day e-MH training programme entitled: “R U Appy” was followed by up to 5 consultation sessions (mean 2.4 sessions). Training focused on download and use of apps, with a focus on the app “Stay Strong” on one of the days.

Uptake of e-MH in the consultation group was moderate (22–30% of participants). Barriers to uptake were grouped into two categories: “Organisational” and “Participant perceptions”. Enablers were also grouped into two categories: “Organisational” and “Positive experience of the consultations sessions.

Features of the organisation acted as both barriers and facilitators to uptake. Where senior staff were supportive, uptake was greater. A good match between resources and work role led to excitement amongst participants about the possibility of using YouTube clips and apps for health education.

Researchers should broaden their focus and definitions of e-MH, emphasising the educational potential of resources, as well as therapeutic potential. Developing criteria for evaluating apps may promote uptake.

Bird (2017) [37]

Australia

Funding:

Australian Federal Government

16 Aboriginal service providers in the health and community-service sectors in regional/rural areas of northern NSW.

Aim: 4–8-month follow-up on use of e-MH resources following an e-MH training programme and to determine what types of e-MH resources they used.

Method: Qualitative evaluation study. 16 semi-structured interviews were transcribed and thematically analysed.

This study was a 4–8-month follow-up of “R U Appy” training, which involved a 3- or 2-day e-MH training programme then up to 6 monthly skills-based consultation sessions delivered face-to-face.

9 of the 16 service providers were using e-MH in their practice for a variety of purposes, including supporting social inclusion, self-care, education, referral, assessment, crisis response, and case management. Use tended not to include treatment of depression/anxiety.

Participants preferred e-MH resources that were easily accessed via mobile devices. Resources for treating anxiety/depression were not preferred, perhaps due to the professional backgrounds of participants, or because mental health concepts were not culturally relevant.

Workforces have characteristics that affect the uptake and use of e-MH resources. There is a need to foster production of culturally relevant resources to support SEWB and treat mental health disorders

Bowen (2012) [15]

United States of America (USA)

Funding:

National Cancer Institute

113 American Indian (AI) youth (12-18 years) recruited during a 6-week residential summer camp for American Indian students (6^th to 12^th grade) in Rapid City, South Dakota.

Aim: To evaluate a smoking prevention and cessation intervention

Method: Randomised control feasibility trial with 1-month follow-up. After baseline assessment, students were randomised to have regular access to the site or not. All participants completed a follow-up assessment 1-month post randomisation.

Self-directed educational programme (“SmokingZine”). Participants were encouraged to access it as often as they like over six weeks and had daily 1-h computer time. Modules covered education, behaviour change goals, positive values and identifying barriers to change.

52% uptake in intervention arm. The intervention did not directly affect smoking behaviour but did alter intentions to use tobacco amongst never-smokers.

Small sample, lack of statistical power. Selection bias- high grade point average and low rate of smoking at baseline. Limited access to the Web at the camp may have reduced engagement. A “group design” for future programmes where youth can use the site together.

Partial support for the potential of the tool for future research, and support for the feasibility of future research on smoking cessation programmes designed for American Indians and Alaska Natives.

Bradford (2015) [38]

Australia

Funding:

Commonwealth Scientific and Industrial Research Organisation (CSIRO)

Non-indigenous researchers from the CSIRO consulted: staff of 1 remote Aboriginal health service; 1 urban Indigenous health institute; and cardiac/ Indigenous health specialists.

Aim: To adapt an established mobile phone delivered cardiac rehabilitation programme for Indigenous people.

Method: Consultation with stakeholders and employment of Indigenous production company. Paper outlines the changes made following consultation.

Smartphone app to delivered over 6 weeks to provide cardiac rehab in the patient’s home in line with their lifestyle. Includes clinical portal, mentoring and educational material.

Modifications included flexibility in the duration of delivery, inclusion of positive measures, use of mentors, a meeting place for using the app and taking physical measures, changes to educational content words, look and feel.

Smartphone programme not yet tested but based on previous research with mainstream populations, the authors anticipate positive results. The adapted smartphone app is ready for further community consultation and trial.

Mobile delivery significantly improves primary outcomes over traditional cardiac rehabilitation care and if replicated in Indigenous populations, the programme has the potential to significantly improve life expectancy

Campbell (2015) [16]

USA

Funding:

National Drug Abuse Treatment Clinical Trials Network; National Institute on Drug Abuse (NIDA)

N = 40 AI/ Alaska Native (AN), mean age 37.5; 47.5% women, recruited via two urban outpatient drug treatment programmes, Northern Plains and Pacific North-west regions.

Aim: To test acceptability of a web-based version of a therapeutic education system (TES) for drug treatment.

Method: Participants completed baseline assessments then 1 week after the intervention phase, follow-up assessments plus qualitative interview.

Self-directed and comprised 32 interactive, multimedia modules based on the Community Reinforcement Approach (CRA). Delivered over 8 weeks on computers in the treatment settings.

TES was acceptable across seven quantitative indices. Qualitative findings indicated (1) content was relevant and (2) acceptability would be enhanced by better AI/AN representation across several content domains, and removal of content that is counter to AI/AN culture.

Acceptability of modules varied according to personal characteristics or experiences of participants, including perceived discrimination and “ethnic experience”. Participants rated those modules with STI/HIV information most highly.

Evidence-based, culturally informed, web interventions may address barriers to treatment in AI/AN communities. Adaptations can be made without losing fidelity. Research should incorporate cultural acceptability and a wider range of implementation issues.

Cowan (2013) [26]

New Zealand (NZ)

Funding: NZ Ministry of Health

N = 2683 completed “sessions” of use of internet link and confidence rating in. N = 207 Maori people completed the program.

Aim: to describe use, impact and reach of an online education tool for preventing sudden infant death.

Method: online tool promoted widely, and basic usage data collected online.

Baby Essentials Online was a self-directed education, 1~15-min session of 24 slides, followed by assessment of “increased confidence” (IC)

Of Maori participants, 53 rated their IC as “low” and 154 rated their IC as “high.”

The greater IC in Maori with no greater time per slide may reflect lower starting knowledge and confidence

Help reducing SUDI in the Maori population, the online tool extended education opportunities beyond the traditional face-to-face delivery mode and is cost-effective

Dellinger (2018) [17]

USA

Funding: National Institute for Environmental Health Sciences; Sault Ste. Marie Tribe of Chippewa Indians

N = 24 (13 women) Anishinaabe (Native American), aged 25-55+, Great Lakes region.

Aim: To describe the development and acceptability of an app “Gigiigoo’inaan”, which aims to improve nutrition via personalised, culturally tailored advice on fish contaminants.

Method: Mixed methods-qualitative and quantitative (survey) feedback obtained during focus groups.

Gigiigoo’inaan [Our Fish] is an app delivered on mobile phone and/or internet that provides personalised risk and benefit information on fish species based on user input information.

61% said they would consume more fish if they had regular access to the app; 75% agreed the app was useful, culturally appropriate and helped them identify fish to eat.

However, some reported confusion about encouragement to eat fish combined with warnings re contaminant levels.

Negative emotions relating to app compounded by: (1) historical distrust; (2) the potential for emotional harm (disproportionate to the actual risk) from learning of above average exposure; (3) concerns that the data may misused to stigmatise Anishinaabe culture, and (4) an attitude of communal privacy.

Testing of the pilot software demonstrates the value of designing culturally adapted risk communication with vulnerable populations. The app may help to regain community interest and faith in natural resources. The findings support the assumption that the community seeks to promote the stewardship of natural resources.

Dingwall (2015a) [39]

Australia

Funding:

Australian Federal Government

N = 138 (70% women, 35% Indigenous), aged 19-74 (M = 40.41, SD 12.86) service providers working with Indigenous people in the Northern Territory

Aim: To evaluate awareness, knowledge and confidence in e-mental health and the AIMhi Stay Strong App

Method: Pre-post questionnaires on confidence and use of e-mental health tools with Indigenous clients.

Face-to-face training programme “Yarning about Indigenous mental health using the AIMhi Stay Strong App”. Duration not provided.

Significant improvements across all measures of skill and knowledge except for confidence in using computers

Limited awareness of e-mental health tools prior to training. The increase in confidence and knowledge post-training is promising but it is not known whether this will translate into use.

E-mental health tools have potential to improve access to culturally appropriate mental health care for Indigenous Peoples with minimal training but more research required into uptake and use.

Dingwall (2015b) [43]

Australia

Funding: Australian Federal Government

15 service providers from rural and remote health services working with Indigenous people in the Northern Territory,

Aim: To assess acceptability, feasibility, and appropriateness of a new e-MH resource for service providers.

Method: semi-structured interviews about barriers, enablers, acceptability and feasibility of use

Clinician-assisted, Interactive app (AIMhi Stay Strong). A brief intervention focusing on worries and strengths, and enabling personal and behavioural goal- setting

Positive feedback on all aspects of the app. Thematic analysis revealed support for the acceptability, feasibility, and appropriateness of the resource amongst service providers

Simple language and visual appeal were identified as strengths. Participants indicated that the app would be particularly useful for client engagement, and that it enabled a client-centred approach. Barriers to use include access to power and internet.

e-MH interventions are likely to make an important contribution to overcoming the burden of poor service access for remote Indigenous clients including new delivery ways for health in remote regions

Fleming (2012) [27]

NZ

Funding: NZ Ministry of Health; NZ Tertiary Education Commission

N = 32 adolescents aged 13-16: 34% Maori; 38% Pacifica; 56% male completed SPARX during school class time.

Aim: To investigate the efficacy of the SPARX programme for symptoms of depression

Method: Randomised wait-list control trial. Immediate vs delayed treatment (5 weeks). 10-week follow-up

SPARX comprises 7 30-min self-administered modules. 1–2 completed / week. CBT-based content including relaxation, problem solving, activity scheduling, challenging negative thinking and social skills.

Reductions in depression from baseline to week 5 compared to control, changes sustained 10-week follow-up. No significant changes in anxiety, locus on control or quality of life.

Good completion rates attributed to graphic interface specifically designed for young people and delivery during class time. Good uptake occurred where the programme was opt-out (i.e. delivered as part of school curriculum) rather than volunteer.

Delivery online and in school helped overcome embarrassment- a known barrier to help-seeking. SPARX has promise as an intervention for young people who may be reluctant to engage in traditional health services.

Fletcher (2017) [44]

Australia

Funding: Young and well Cooperative Research Centre; University of Newcastle

N = 20 Aboriginal fathers aged 18-25 recruited through ACCHS and community networks in urban, regional and rural locations.

Aim: To test the acceptability and feasibility a website with tailored support to young fathers and to adapt and test a mobile phone-based text message and mood-tracker program.

Methods: Participatory qualitative methods including: “yarn-up” discussions, filming fathers’ stories, and SMS messaging. Participants and community gave feedback on all aspects.

Stayin on Track is a website with information, films and SMS messaging for young fathers. SMS was used to monitor mood and send encouraging messages. Participants were supported by senior mentors. The website was promoted via community networks and ACCHS staff.

Links sent by SMS on parent routines and “baby talk”. Information on crying, post-natal depression and bonding for dads were not highly accessed. Most participants reported positive mood (91.5%). Community feedback was positive.

Key to the success of the programme was the close research partnership with the communities involved, and the involvement of the fathers in developing the website content, and the involvement of mentors. Online delivery can help to overcome barriers to access to culturally appropriate resources.

Providing tailored online resources to Aboriginal fathers is feasible and acceptable. Through their involvement in the project, the young fathers saw themselves as mentors who could support other young men, thus enhancing project sustainability. Authors recommend refining the mentoring model and conducting further evaluation.

Gorman (2013) [18]

USA

Funding: source not provided

N = 21: 15 AI/AN women of child-bearing age representing 9 tribes, and 6 key informants in California.

Aim: To modify and evaluate a mainstream web-based behavioural intervention (SBIRT) on prenatal alcohol use for AI/AN women.

Method: semi-structured focus groups and interviews. Data were transcribed; cross-case inductive analysis was used to identify themes.

Self-administered Web-based programme for screening and prevention of prenatal alcohol use, with or without personalised feedback.

5 themes: Make the programme relatable; stress confidentiality; incorporate family/ community focus; tailor content to community; and include information on health effects for children.

Effectiveness not known. Participatory development processes were essential for building relationships and trust in context where there is low trust of research.

This programme has the potential to provide a culturally appropriate, cost-effective approach to assess and prevent prenatal alcohol use.

Jernigan (2011)

USA [19]

Funding: source not provided

N = 54: 27 Native American (AI/AN) representing 18 tribes in urban and reservation settings, and 27 non-Native) participants. All had diabetes, 86.5% female. Participants recruited online.

Aim: to examine the feasibility and cultural appropriateness of the Stanford Internet Diabetes Self-Management Workshop (IDSMW) with AI/AN population.

Method: Mixed methods process evaluation.

A 6-week peer-led internet-based workshop covering nutrition, complications, medications and managing emotions. Participants log in three times/week for 2 h including reading online content.

23 AI/AN participants participated regularly, 4 sporadically. Feedback indicated workshop was culturally acceptable because of the participation of AI/AN people, and that all AI/AN discussion groups were preferred.

The intervention is adaptable due to a peer-led mechanism of delivery. It was considered culturally appropriate with limited adaptation. Participatory approaches to recruitment facilitated implementation.

It is feasible to implement an Internet-delivered disease self-management workshop within a diverse AI/AN population. Several participants volunteered to be peers in future online workshops.

Kypri (2013)

NZ [28]

Funding: NZ Alcohol Advisory Council

N = 2355 Maori students aged 17-24 at seven of NZ’s 8 universities were screened for harmful alcohol use (AUDIT-C). Those screening positive (n = 1789) recruited to the research trial. N = 850 control, N = 939 intervention.

Aim: to test the effectiveness of a web-based alcohol screening and brief intervention (e-SBINZ) for hazardous drinking

Method: Parallel, double-blind, multi-site, randomised controlled trial. Follow-up questionnaire 5 months post-randomisation.

Web-based alcohol assessment and personalised feedback on health risks, other risks, expenditure and comparative data, as well as tips to reduce harm. The intervention took <10 min post screening.

Relative to controls, participants receiving intervention drank less often, less per drinking occasion, less overall and had fewer academic problems. These differences were statistically significant.

It is possible to reach large numbers of Maori people with hazardous drinking via the internet. E-SBINZ is extremely low cost. Personalised feedback avoided framing Maori student drinking in terms of deficit.

e-SBINZ reduced hazardous and harmful drinking amongst non-help seeking Maori students and has the potential to lead to ongoing public health benefit in the long term, especially with annual implementation in all new Zealand universities. Further generalisability not clear.

Levine (2009) [20]

USA:

Funding: US Army. COI: 2 authors own stock (<5%) in the company that has licensed MyCareTeam technology.

N = 109 AN (>18 years) with type 1 & 2 diabetes mellitus recruited via Indian Health Centers in Alabama, Idaho, and Arizona. Gender/age not reported.

Aim: To test whether interaction with a web-based diabetes management app: (MyCareTeam®) increased monitoring of blood glucose (BG) levels and health care provider (HCP) interaction.

Method: non-randomised prospective feasibility study.

The app that provided feedback on blood glucose levels, culturally adapted information, and facilitated timely interaction between patients and HCPs through text messaging.

Use of the app varied, with 46/109 using it 2/month. The more participants used the app, the more they tested their BG and interacted with their HCP. The messages from HCPs seemed to help motivate use of the app.

One of the key mechanisms by which the app worked was increasing the sense of closeness between the patient and HCP, increasing trust and accountability. The authors suggest that apps without this personal element may not be as effective.

Use of the app encouraged HCP-patient interaction and patient-centred communication, which in turn increased BG monitoring. Authors suggest further research on the relationship between messaging and clinical health benefits.

Montag (2015) [21]

USA

Funding: National Institute of General Medical Sciences

N = 263 AI/AN women of child-bearing age in Southern California, recruited via health clinics. N = 121 intervention N = 142 control (TAU)

Aim: to assess the effectiveness of SBIRT at reducing risky drinking and risk of alcohol-exposed pregnancies (AEP). Method: Randomised trial with follow-up questionnaires at 1, 3 and 6 months.

SBIRT was an adapted from eCHECKUP TO GO, a brief (20 min) intervention comprising: web-based survey with personalised feedback including analysis of risk, and helpful advice that could be printed out confidentially.

No difference between intervention and control groups. Risky drinking decreased in both groups: drinks/ week, (p < 0.001); frequency binge episodes/2 weeks, (p = 0.017) and risk of AEP (p < 0.001) at 6 months post intervention.

Baseline factors associated with decreased alcohol consumption at follow-up included the thinking other women group drink more, more binge episodes in the past 2 weeks, needing treatment for depression.

Null finding suggests that assessment alone, without intervention, may be enough to decrease risky drinking and vulnerability to AEP. Contraceptive could be added to future interventions to reduce vulnerability to AEP.

Phillips (2014) [40]

Australia

Funding: Australian Government Department of health and Ageing Hearing Loss Prevention Program.

N = 53 (30 intervention, 23 control) caregivers of Aboriginal children living in remote community households in NT, with access to a mobile phone in the household.

Aim: To test whether WBTI for families of children with tympanic membrane perforation (TMP): (i) increased clinic attendance, (ii) improved ear health and (iii) provided a culturally appropriate method of health promotion.

Method: multi-centre, parallel group, RCT.

One ear health Multimedia Media Service (MMS) in the local Indigenous language sent every 4 days, ±24 h window over 6 weeks. Videos were short, animations of Indigenous role models, accompanied by personalised text messages in English with a prompt to visit the clinic.

No significant difference between groups in clinic visits per child, healed perforation, middle ear discharge or perforation size. Majority were happy to receive the messages. Ten families in the intervention group reported not receiving the messages.

Culturally appropriate MMS that could be shared amongst families, the video messages may have been unclear or confusing, and simple text messages may be more effective. Uptake was impacted by events in the community unrelated to the trial.

Mobile phone-based MMS and text messaging intervention was acceptable, but it had no short-term impact on clinic attendance or ear health. A study over a longer time period may be more informative 4`.

Povey (2016) [41]

Australia

Funding: Northern Territory (NT) Department of Health

N = 9 (3 male; 18–60 years old) Aboriginal and Torres Strait Islander community members without serious mental illness in Darwin, NT.

Aim: To explore acceptability of two culturally responsive e-mental health apps. Method: 3 3-h focus groups. Transcripts were member-checked and analysed thematically.

The AIMhi Stay Strong iPad app is a clinician-assisted therapeutic goal setting tool.

iBobbly is a self-help suicide prevention app for mobile device based on acceptance commitment therapy.

Findings indicated that acceptability was influenced by characteristics of the person (e.g. mental health), environment (e.g. stigma) and apps (e.g. ease of use.

Uptake and use were reportedly influenced by motivation to change; technological competence; literacy and language; internet or phone access; free download; ease of navigation; cultural relevance, voices, animations.

E-mental health tools can improve the wellbeing of Indigenous people. There was strong support for the concept of e-mental health apps and optimism for their potential. Specific adaptations may aid uptake.

Raghupathy (2012) [22]

USA

Funding: National Institute on Drug Abuse

Rural and urban AI/AN youth, other service providers and artists collaborated on the development process in northern California. N = 45 AI/AN youth aged 11-13 participated in the final review.

Aim: To describe the adaptation of a drug prevention intervention into a low-cost computer-based drug prevention intervention: Honouring Ancient Wisdom and Knowledge (HAWK2)

Method: Descriptive review of development process

HAWK2 comprised 7 lessons, 25–30 min each, which could be implemented flexibly. Total exposure 3.5 h. Evaluation at the end of each lesson

In the final review with, HAWK2 received high mean ratings on likeability (4.8/5), ease of use (4.5/5), comprehension (4.6/5), and future use (5.0/5). Practitioners also gave positive feedback.

Strengths were: Recognising the influence of specific cultural and contextual variables; building on an existing evidence-based program; and Integrating community perspectives.

Computer-based interventions are a cost-effective way of engaging youth in prevention programming. Future studies of effectiveness and feasibility are needed.

Ram (2014) [29]

NZ

Funding: Asthma Foundation of NZ

N = 761 consecutive patients and 18 nurses in primary care. N = 44 were Maori patients, n = 18 Pacifica. Age ranged from 5 to 64 in the Waitemata region of Auckland.

Aim: To evaluate the effectiveness of the online intervention at reducing exacerbations, hospital admissions and emergency presentations, use of corticosteroids and bronchodilator reliance.

Method: Retrospective cohort study. Patient data were compared pre-post intervention.

GASP is an online decision support tool for primary care, providing service providers with skills & knowledge to undertake a structured asthma assessment. The GASP tool is also shown to patients.

Maori and Pacifica patients showed a significant decrease in ED presentations but no differences in risk of exacerbations, use of other treatments or hospital admissions. Asian and NZ European patients showed benefit on all measured outcomes.

The difference in benefit may be attributed to the significantly greater burden of respiratory illness in Maori and Pacifica and Maori populations, including a hospital admission rate twice that of New Zealand Europeans.

GASP in primary care has the potential to translate into significant clinical improvements for but its potential for use in Maori and Pacifica populations needs to be further explored.

Riddell (2007) [30]

NZ

Funding: Health Research Council of NZ; National Heart Foundation

N = 19,164: Maori = 1450 (7%). Mean age: 53.2, 46% female. Participants attended “ProCare” primary health care providers in Auckland.

Aim: To describe the cardiovascular disease (CVD) risk factor status and risk management of Maori vs non-Maori using PREDICT-CVD

Method: Patients opportunistically assessed in routine primary care practice.

PREDICT-CVD is a web-based clinical decision support programme for CVD risk assessment and management. It has been shown to increase CVD risk assessment rates in primary care.

Maori were assessed 3 years younger than non-Maori. Maori with CVD received more anti-coagulants, BP-lowering and lipid-lowering medications. Maori with Ischemic heart disease were half as likely to have a revascularisation procedure.

An electronic decision support programme generated CVD risk burden and risk management data for Maori and non-Maori populations in routine clinical practice in real-time.

When Maori specific equations replace those based on a white, middle-class American population, the PREDICT-CVD will provide a world-class data system that can identify gaps in care for Maori patients and enable action on them.

Robertson (2007) [23]

USA

Funding: South Dakota State University Foundation

N = 52 Lakota Sioux AN with type 2 diabetes individuals (33 intervention group, 19 controls), living on Northern Plains Indian Reservation, Sioux Falls, South Dakota.

Aim: To develop and test a culturally appropriate web-based interactive programme (Keya Tracker) for management of type 2 diabetes.

Method: Randomised control trial. Pre-post data collected on HbA1c, exercise, diet, cultural activities, and social activities.

Kaya Tracker was an interactive website developed with input from tribal Elders. Content covered nutrition, physical activity, social and cultural activities. Participants logged-in 3 times per week for 24 weeks.

HbA1c control improved in the intervention group relative to controls (p = .025), suggesting improved disease control and programme effectiveness. Four participants did not complete the intervention.

Effectiveness may be due to the flexibility of the online delivery. Also, the website was designed for its audience, therefore accounting for Lakota Sioux understandings of health.

Use of a culturally appropriate Web-based interactive programme may be a viable tool to assess with diabetes-related lifestyle change. A larger study is warranted.

Shepherd (2015) [31]

NZ

Funding: NZ Ministry of Health; Rotary Club of Downtown Auckland; University of Auckland. COI: 2 authors have financial interest in SPARX.

N = 26 Māori people, taitamariki (adolescents); taitamariki mothers (aged 16–18); and whanau (family) in Auckland.

Aim: To describe experiences of a prototype computerised therapy programme for treating mild to moderate depression.

Method: Mixed method Kaupapa Maori research. 7 focus groups followed by a survey. General Inductive/thematic analysis was used to generate themes.

Smart, Positive, Active, Realistic, X-factor thoughts (SPARX) provides free, computerised (cCBT); online computer programme using avatars. Players are led through 7 fantasy “realms” each lasting 30–40 min. 1–2 levels completed over 3–7 weeks.

Good face validity; cultural relevance for Maori; Whanau are important for young people’s wellbeing. Ideas for improvement related to use of clinical and Maori language, reducing text, and using audio.

Positive evaluation and acceptance were aided by cultural relevance of both process and content. Culturally adapted mental health interventions are thought to be much more effective.

Participants supported the contemporary Maori design of the program. SPARX was the first programme of its kind and may be used as a model for other cCBT interventions.

Shepherd (2018) [32]

NZ

Funding: NZ Ministry of Health; Rotary Club of Downtown Auckland; University of Auckland; Te Rau Matatini

N = 6 Māori taitamariki (adolescents) aged 14-16 (mean 14.6), in two schools in the wider Auckland area. Participants had mild-moderate depression and low risk for self-harm.

Aim: To explore adolescents’ opinions about a programme for treating mild/moderate depression in young people

Method: Exploratory qualitative study using semi-structured interviews. Thematic analysis.

The SPARX programme is an online, gamified cCBT programme using avatars for treating mild – moderate depression.

Themes indicated that: (1) the programme was helpful because it taught CBT skills; (2) It was engaging due to Maori designs; (3) The characters provided helpful advice; (4) It was both enjoyable and challenging; 5) Writing thoughts and feelings was helpful.

Māori designs appeared beneficial, as this seemed to enhance cultural identity. SPARX was like a computer game that could help with depression. A breathing relaxation exercise was valued

Māori designs were appropriate and useful. The ability to customise the characters with Māori enhanced cultural identity. A much larger study should be conducted to explore the efficacy of SPARX.

Starks (2015) [24]

USA

Funding: Patient-Centred Outcomes Research Institute

Multiple groups of stakeholders consulted within South Central Alaska Native Foundation had input into tool development. N = 20 patients and 7 service providers participated in piloting the tool.

Aim: To report on the multi-year stakeholder engagement process for the development of the patient-centred “Depression Management – Decision Support Tool (DM-DST)”.

Method: Qualitative analysis of multiple data sources including interviews with patients and providers, meeting notes, consultations and pilot testing.

Electronic, patient-centred, depression management decision support tool (DM-DST) with two components: an interactive tool to facilitate discussions between patients and providers and a website with detailed information for patients.

Stakeholder engagement resulted in substantial modification of the original tool, including breaking it into two parts, incorporating AN imagery and cultural concepts including faith, family and cultural expressions of depression and solutions. There was a focus on reducing stigma.

Multi-stakeholder engaged research allowed the researchers to understand the diverse values and needs of end-users. The tool was considered interesting, useful, and thought-provoking with the potential to foster conversations with primary care providers.

The process employed as relevance to other primary care systems seeking to improve and individualise treatments. The tool enhances patient-centred decision making. Future research will test its effectiveness is an RCT.

Taualii (2010) [25]

USA

Funding: Spirit of Eagles Special Populations Network (NIH)

N = 25 urban American AI/AN young people, aged from 12-18 in Seattle.

Aim: To adapt, modify and test for useability an existing smoking prevention and cessation resource.

Methods: Focus groups were conducted in 2 phases, first to adapt and then to test the usability of the SmokingZine website.

SmokingZine an e-health website targeting behaviour change relating to youth smoking prevention and cessation.

Participants were receptive to the use of the intervention tool and offered ideas for changes to make it more culturally relevant. In phase 2, participants found the site easy to use and relevant to smoking cessation.

There was a lot of overlap between mainstream and AI/AN youth perspectives on smoking. Including cultural distinctions in a new website was acceptable and valued, although computer access not ubiquitous.

These findings provide justification for a full-scale trial of the SmokingZine website. Future research should include both urban and rural AI/AN youth and consider delivery through schools.

Tighe (2017) [42]

Australia

Funding: Australian Government Department of Health and Ageing

N = 62 young men (22, 36%) and women (aged 18–35 years) in remote communities in the Kimberley region of north-Western Australia. 4 were non-Aboriginal, the remainder were Aboriginal and/or Torres Strait Islander.

Aim: To evaluate the effectiveness of a self-help mobile app for suicide prevention.

Method: Randomised waitlist control trial. Measures were taken face-to-face at baseline and after the intervention for both groups. The control group had a final follow-up assessment at 12 weeks.

iBobbly was a mobile app that targets suicidal ideation, depression, psychological distress and impulsivity using Acceptance Commitment Therapy approaches. Three content modules and three self-assessments, completed over 6 weeks.

Data were available for 40 participants. Significant pre/post changes on suicide ideation in the iBobbly arm (p = 0.0195), but not when compared with waitlist arm. iBobbly group showed reductions in depression and distress scores compared with waitlist. Waitlist improved after 6 weeks of app use.

Uptake was aided by the collaborative development process. Acceptance was indicated by the promotion of the app by the target community. Technical/ connectivity failure prevented some from providing final data.

The app, using acceptance-based therapy reduced distress and depression but did not show significant reductions on suicide ideation or impulsivity. Study highlighted the importance of co-design.

Tonkin (2017) [45]

Australia

Funding: NHMRC; National Heart Foundation; NT Government Department of Health

N = 36 smartphone users (aged 18–35 years) in two remote Indigenous communities in NT. There were 10 participants per community in each phase of research.

Aim: To develop and test a prototype app to improve nutritional intake relating to sugar-sweetened beverages (SSB).

Method: Formative phase included simulated grocery selection activity, semi-structured interview, and survey. End-user testing phase involved a “think aloud” test and interview on user satisfaction.

Self-administered Smartphone app including assessment and feedback on SSB intake, behavioural challenges, interactive exercises and games.

Drivers of food choice/behaviour included taste, family, health, price and convenience. Mixed methods data on usability indicated that participants found the app useful & were confident using it, with some suggested modifications.

Complex set-up and log-in inhibit use. Dissemination of apps should be contextually embedded with many avenues available. Learnings about the social dynamics of remote communities in this study may have relevance to other disadvantaged communities.

Recommendations included: formative research needs to be prioritised in project plans; use mixed methods; patterns of technology use may be different in different locations; include non-written communication; local language; engaging graphics.

Verbiest (2018) [33]

NZ

Funding: Healthier Lives He Oranga Hauora National Science Challenge

Partnership between Maori, Pasifika and European academics, Maori health providers and community members in Wellington and Auckland regions.

Aim: (a) to provide overview of co-design methods and processes; (b) to describe how co-design was used to select behavioural determinants and change techniques.

Method: 6-step participatory co-design process conducted over 11 months. Focus groups, photographs, notes and observations were thematically analysed.

Self-administered mHealth tool (smartphone app) for prevention of non-communicable disease, incorporating contemporary Maori and Pasifika theoretical frameworks of health and health promotion.

Domains prioritised: (a) physical activity, (b) family, and (c) healthy eating (including fruit and vegetable gardening; Table 1). Māori community partners identified additional ethnic-specific themes relevant for overall Māori health and wellbeing.

By using ethnic-specific models of health for interpreting the co-design data, the selected behavioural barriers, enablers, and change techniques align with the cultural needs and wants of the user.

Authors suggest future tailored, lifestyle support (mHealth) interventions for Indigenous and other priority groups should be co-designed and look beyond Western approaches to ensure they are evidence-based and culturally relevant.

Whittaker (2006) [34]

NZ

Funding: Waitemata District Health Board; Future Forum; National Heart Foundation

80 General Practitioners (GPs) providing care to Maori and non-Maori people in New Zealand. N = 474 (28.2%) Maori patients pre- and n = 484 (25.7%) post- intervention.

Aim: To determine if an electronic assessment and management tool for CVD could increase risk assessment but not inequalities.

Method: Retrospective audit of GPs using the tool’s electronic medical records (EMRs)

PREDICT-CVD is a web-based decision support tool to facilitate risk assessment for GPs to use in the management of CVD in primary care.

Maori participants were significantly different from non-Maori on all measured parameters. Maori were younger, had more diabetes, lower SES and higher rate of smoking. Rate of risk assessment increased in both groups.

Rates of documented risk assessment were low overall. 7.2% of audited EMRs had no ethnicity stated and coded as non-Maori, which may have resulted in under- counting of Maori.

The implementation of the tool should not occur without an implementation program, and other changes to increase responsiveness to the needs of those at risk of CVD, such as taking risk assessment into community settings.