Use and uptake of web-based therapeutic interventions amongst Indigenous populations in Australia, New Zealand, the United States of America and Canada: a scoping review

Background Barriers to receiving optimal healthcare exist for Indigenous populations globally for a range of reasons. To overcome such barriers and enable greater access to basic and specialist care, developments in information and communication technologies are being applied. The focus of this scoping review is on web-based therapeutic interventions (WBTI) that aim to provide guidance, support and treatment for health problems. Objectives This review identifies and describes international scientific evidence on WBTI used by Indigenous peoples in Australia, New Zealand, Canada and USA for managing and treating a broad range of health conditions. Eligibility criteria Studies assessing WBTI designed for Indigenous peoples in Australia, Canada, USA and New Zealand, that were published in English, in peer-reviewed literature, from 2006 to 2018 (inclusive), were considered for inclusion in the review. Studies were considered if more than 50% of participants were Indigenous, or if results were reported separately for Indigenous participants. Sources of evidence Following a four-step search strategy in consultation with a research librarian, 12 databases were searched with a view to finding both published and unpublished studies. Charting methods Data was extracted, synthesised and reported under four main conceptual categories: (1) types of WBTI used, (2) community uptake of WBTI, (3) factors that impact on uptake and (4) conclusions and recommendations for practice. Results A total of 31 studies met the inclusion criteria. The WBTI used were interactive websites, screening and assessment tools, management and monitoring tools, gamified avatar-based psychological therapy and decision support tools. Other sources reported the use of mobile apps, multimedia messaging or a mixture of intervention tools. Most sources reported moderate uptake and improved health outcomes for Indigenous people. Suggestions to improve uptake included as follows: tailoring content and presentation formats to be culturally relevant and appropriate, customisable and easy to use. Conclusions Culturally appropriate, evidence-based WBTI have the potential to improve health, overcome treatment barriers and reduce inequalities for Indigenous communities. Access to WBTI, alongside appropriate training, allows health care workers to better support their Indigenous clients. Developing WBTI in partnership with Indigenous communities ensures that these interventions are accepted and promoted by the communities.


Background
Indigenous populations in Australia, New Zealand, the United States of America (USA) and Canada carry a greater burden of ill-health than the general populations in their respective countries [1]. In each of these countries, Indigenous populations also experience barriers to receiving optimal health care due to mistrust of the health system resulting from historic and current mistreatment, language and cultural differences and living in geographically remote locations [1]. Globally, developments in health information and communication technologies (ICT) have been applied to overcome such barriers and to enable greater access to basic and specialist care [2].
In recent years, technological advances have also led to the development of therapeutic interventions delivered electronically for a range of health conditions. The focus of this review is on web-based therapeutic interventions (WBTI), which are self-guided or clinicianassisted programmes delivered via the internet that aim to provide guidance, support and treatment for health problems. The proliferation of mobile devices, including smart phones and electronic tablets, means that webbased programmes and mobile applications ("apps") can be accessed at low cost by a range of populations, including culturally and linguistically diverse, or other populations who may be otherwise disengaged with the health system for a range of reasons.
In Australia, despite the challenges inherent in remote living, compounded by socioeconomic disadvantage, Aboriginal and Torres Strait Islander populations have high rates of social platform use, indicating high levels of internet connectivity [3]. The recent roll-out of the "National Broadband Network" (NBN) in non-urban areas and other advances in technology have resulted in the rise of telecommunication access in remote areas, where internet access was previously limited [4]. In recent years, the increase in use of social platforms has been significantly greater amongst Aboriginal and Torres Strait Islanders compared with that for all Australians, and a high level of engagement with social platforms has been evident in the health sector [5][6][7]. Together, advancements and high level use of ICT by Indigenous Australians across all areas of remoteness and sociodemographic spectrum clearly indicate a potential to engage with individuals directly through social platforms, particularly with younger people.
The use of digital health platforms has been advocated to incorporate a wider approach to include social determinants of health and wellbeing [5], given the feasibility of capturing personalised health-related social and behavioural information that was not previously accessible, with direct implications to people living with chronic diseases. Worldwide, there are over 250,000 different consumer-targeted mobile health apps, though few have been rigorously evaluated regarding the accuracy of information they provide, privacy and digital security protections, and their usability, functionality and effectiveness in the context of health [8]. As the use of online therapies continues to grow, this review of international evidence on WBTI for health conditions amongst Indigenous populations is timely.
A previous scoping study has examined the evidence for the effectiveness of web-based and mobile technologies in health promotion, specifically to reach Indigenous Australians [9]. This valuable piece of work focused on social media and mobile apps primarily for smoking cessation, many of which did not appear in the peerreviewed literature. The current review provides an update on the peer-reviewed evidence of the acceptability, validity and effectiveness of WBTI for a broad range of health conditions, extending the review to include WBTI developed with Indigenous people internationally for communicable and non-communicable diseases, mental health conditions (including the broader concept of social and emotional wellbeing), or issues relating to the use of harmful substances, and problem gambling. The objective of this scoping review is to identify and describe the available international scientific evidence on WBTI used by Indigenous peoples in Australia, New Zealand, Canada and USA for managing and treating health conditions. These four countries were included due to similar persistent patterns of inequities that have arisen in these countries since colonisation, as well as geographic and demographic similarities such as remoteness from health services and differing language, culture and concepts of health and illness from the dominant culture [1]. Additionally, these four countries have other commonalities which allow for comparison; they are developed, democratic, wealthy countries with similar standard of living and life expectancy [10].

Methods
The study protocol for this scoping review has been published previously [11]. Methods followed the procedures outlined by the Joanna Briggs Institute [12,13] with reporting adhering to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines scoping review extension [14]. The relevant PRISMA checklist is included as an additional file.

Information sources
A systematic search was conducted of the following databases: PubMed, CINAHL, Embase, ATSIHealth via Informit online, Web of Science, APAIS Health databases, Australian Indigenous Health InfoNet and the Primary Health Care Research Information Service (PHCRIS). A search for unpublished studies was conducted by accessing Mednar, Trove, Google, OCLC WorldCatDissertations and Theses, and Proquest Dissertations and Theses. The search in Trove was limited to theses only, as the assumption was made that other publication types would be captured in the other databases. To capture additional literature, a search of websites and clearing houses that provided information, links and resources relating to Indigenous health in each of the four countries that are the focus of this review was conducted using initial keywords including the following: Indigenous, Aboriginal, Torres Strait Islander, Maori, First Nations, First Peoples, Metis, Inuit, Native American, eHealth, telehealth, internet-based intervention and web-based therapeutic tool.

Search strategy
As outlined in the scoping review protocol [11], a fourstep search strategy was followed in consultation with a research librarian, with a view to finding both published and unpublished studies. An initial limited search of PubMed was undertaken. The final search strategy for PubMed can be found in Table 1. An analysis of the text words contained in the titles and abstracts, and of the index terms used to describe articles then informed the development of search strategies tailored for each information source. A second search using all identified keywords and index terms was undertaken across all other information sources. The reference list of all studies selected for inclusion was screened for additional studies. The search strategy allowed for authors to be contacted and experts consulted with a view to accessing any unpublished data or for clarification of published information; however, this was not necessary in practice. The search was conducted on 10 April, 2019.

Inclusion criteria Date range
Studies published from 2006 to 2018 (inclusive) in English were considered for inclusion. This timeframe was considered sufficient to capture up-to-date evidence on WBTI that have grown in popularity in recent years.

Publication status
Peer-reviewed and grey literature meeting the inclusion criteria were considered for inclusion.

Participants
Studies assessing WBTI designed for Indigenous peoples of any age in Australia, Canada, USA and New Zealand were considered for inclusion in the review. Participants could be accessing the WBTI to prevent, manage or treat their own health condition; or could be healthcare providers, friends or family members accessing a WBTI to assist an Indigenous person with a health condition. Studies were considered if more than 50% of participants were Indigenous, or if results were reported separately for the Indigenous participants.

Concept
The focus of this review was on the use and uptake of WBTI by Indigenous people. The range of possible health issues the WBTI could address was deliberately broad and included chronic physical illness, communicable disease, mental health conditions and issues relating to social and emotional wellbeing, use of harmful substances or gambling. Studies were considered for inclusion if they provided information on WBTI used by individuals or groups: either autonomously or with assistance, to assess, manage or treat health conditions by (a) modifying lifestyle behaviours, (b) promoting social and emotional wellbeing and resilience, (c) supporting adherence to treatment regimens, (d) increasing motivation to reduce risky behaviours and (e) providing and supporting strategies to reduce dependence on alcohol, prescription drugs, illicit substances or gambling. Evaluations of websites that only provide health education without any interactive or therapeutic content were excluded. This included interventions involving health information kiosks or telehealth as the sole intervention strategy.

Context
Health-related WBTI accessed in any setting in Australia, New Zealand, Canada and USA were included.

Selection of sources
Following the search, all identified citations were uploaded into Endnote TM (Version X8.1, Clarivate Analytics, Philadelphia, USA) and duplicates removed. Citations were then entered into an online systematic review management system (www.covidence.org, 2019, Veritas Health Innovation Ltd, Melbourne, Australia). Titles and abstracts were screened against the inclusion criteria by one researcher (RR), as well as independently by one of two other researchers (SH, IF). Disagreements were resolved through discussion between all three reviewers. Studies that potentially met the inclusion criteria were retrieved in full and imported into Covidence for full text review. The full texts of selected studies were assessed in detail against the inclusion criteria by at least two reviewers (RR, and either SH, FS or IF). Full text studies that did not meet the inclusion criteria were excluded and reasons for exclusion recorded.

Data charting and synthesis
Two data extraction tools were developed for this scoping review [11], which were further refined during the data charting process. This tool facilitated the extraction of the data mapped to the variables outlined in Table 2.
Extracted data was synthesised and reported under four main conceptual categories: (1) types of WBTI used, (2) community uptake of WBTI, (3) factors that impact on uptake and (4) conclusions and recommendations for practice.

Sources of evidence
The systematic searches identified 8182 references and one additional reference was identified through other sources ( Fig. 1). After duplicates were removed, there were 1618 unique papers for review. The large number of duplicates stems from many studies being duplicated across multiple databases. Title and abstract screening excluded 1420 references, and a further 166 papers were excluded on full-text review, resulting in 31 studies meeting the inclusion criteria for this scoping review.

Country
Country and population where the study was conducted.
WBTI Name of the web-based therapeutic intervention.

Aim
Purpose of the WBTI (e.g. treatment, education, adherence, chronic disease management)

Health condition
The health condition targeted by the WBTI.

Participants
Descriptive demographics about the study population Delivery mode WBTI components, frequency intensity and duration of use, self or clinician administered, or clinician assisted

Context
The setting where the study was conducted (e.g. health service or community setting, geographic location (urban, rural, remote), other relevant details reported by authors.

Design
The study design.

Outcomes
The key outcome measures for the study.

Results
Whether the WBTI had a positive or negative change, or no change.

Explanation
Explanations provided by the authors for uptake and treatment effects.

Findings
Author's conclusions, interpretations and recommendations.

Uptake and effects of WBTI
The bulk of the sources reported improved health outcomes for Indigenous people [15, 16, 18-20, 22, 24, 28, 31, 33-38, 41]. For the three studies that reported uptake, voluntary uptake of WBTI was between 30 and 56% [15,27,36,37]. The remainder of the sources had the WBTI as a prescribed component of the reported intervention or evaluation study so rate of uptake is not relevant; however, contextual factors identified by study authors as influences on uptake, use and acceptability are discussed below.
None of the WBTI approaches had a negative impact on participants. However, some WBTI were more successful than others. Two randomised clinical trials reported statistically significant differences in quantitative measures of depression amongst Indigenous adolescents (USA and NZ) who used WBTI "apps" compared to those who did not [27,42], while a qualitative study found substantial improvements in mood amongst Maori adolescents who used a gamified app [32]. An interventional study using WBTI with Native Americans for diabetes control showed a statistically significant improvement in glycated haemoglobin levels [23], and an educational tool for preventing sudden infant death in New Zealand significantly increased the confidence of Maori people to discuss infant sleep safety with others compared with non-Indigenous people [26].
Two sources reported no impact of the intervention. In the USA, risky drinking behaviour by women living in California decreased regardless of whether they received the WBTI or "usual care" [21]. In Australia, while health messages sent via text message did not impact on clinic attendance for children with otitis media [40], the content delivered in local Indigenous languages was found to be culturally appropriate and recipients were happy to receive the information.

Explanations for uptake
While some sources provided no explicit explanations for uptake success or failure [18,30,35], most did. Sources suggested a variety of factors that could improve WBTI uptake; however, the most important was ensuring that WBTI were designed for the audience [23,44], culturally relevant and appropriate [40,41,43], by having culturally relevant graphics, voices and animations [40], and showing traditional practices, culture and Indigenous peoples [16,44]. It was also important that content was matched to participants' values and experiences. For example, Campbell et al. [16] reported that ratings of some modules varied according to experiences of discrimination or mainstream comfort. Cultural appropriateness of the WBTI was explicitly discussed and/or evaluated in all but four sources [26,30,34,35].
Where authors discussed cultural appropriateness, it was linked to better outcomes in terms of acceptability, uptake and impact, whether or not this was formally evaluated. Seven sources reported recommendations from their study populations on features to improve so as to ensure the WBTI contain a greater volume of culturally appropriate content [16,30,33,34,40,44].
In addition, sources reported that users wanted WBTI to have an innovative and visually appealing format [43] and be useful [24,43], interesting [24] and thoughtprovoking [24]. These interventions fostered conversations [24] and resulted in improved patient-practitioner relationship which led to better health monitoring by patients [20,29]. However, one source reported that videos sent via multimedia messaging services may be unclear or confusing and suggested that simple text messages may be more effective [40]. Users like the flexible delivery that WBTI allow [23,38] and want WBTI to be easy to use [41,43] and customisable [38]. However, users also preferred to be able to download the "app" or software for free [41]. Limited access to internet or a phone were found to be prohibitive factors by users [15,41], with mental health workers reporting significant organisational and personal barriers to accessing mental health web-based apps [36]. Systemic or policy contexts that influenced uptake and use included the following: organisational support for the WBTI [36], access to the internet or other technology due to cost or the      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 webbased 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, BPlowering and lipidlowering 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 realtime.
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.

Recommendations and conclusions from the sources
Culturally appropriate, evidence-based WBTI have the potential to improve mental health [27,32,42], address substance abuse treatment barriers [16], improve selfefficacy and self-management in healthcare [23,26] and reduce inequalities in access to healthcare services, for Indigenous communities. WBTI are a cost-effective method of delivering information and engaging target populations, such as youth [22,28] and pregnant women [18], to reduce hazardous and harmful alcohol intake. In fact, one source reported that using a WBTI to selfassess risky drinking behaviour may be enough to influence behavioural change, without implementation of an intervention [21]. Thus far, evaluations of smoking cessation WBTI for Indigenous populations have been limited to America [15,25]. These evaluations concluded that additional long-term, rigorous research is needed to assess WBTI approaches to keep American Indian and Alaskan Native youth from becoming regular smokers [15] and that future research needs to include both urban and rural Indigenous youth [25], highlighting that to date no online tobacco programmes have been designed specifically for these populations [15].
Sources that evaluated the use of mental health WBTI for Indigenous populations concluded that these interventions are likely to be important in overcoming poor access to services for remote communities [39,43], or for youth that might be reluctant to engage in traditional health services [27]. Further, developing WBTI in partnership with Indigenous communities ensures culturally appropriate interventions that are accepted and promoted by the communities [24, 31-33, 42, 44], and lead to improved wellbeing of Indigenous people [41]. In addition, improved access to culturally appropriate WBTI tools, and training in how to use these tools, allows mental health workers to better support their Indigenous clients [36,37,39].
Cardiovascular disease risk data for Maori people can be successfully generated in real time through the use of an electronic decision support tool [30]. In addition, cardiac rehabilitation care delivered through WBTI platform has the potential to significantly improve outcomes for Indigenous populations [38]. However, other researchers suggest that the use of WBTI for cardiac care should not occur in isolation, instead emphasising that WBTI should be complemented by a comprehensive care program [34].
Implementing culturally appropriate WBTI for the selfmanagement of diabetes has been shown to be feasible [19]. The use of such platforms has been shown to improve diabetes control in Indigenous populations [23], possibly because these interventions may increase the frequency patients monitor their blood glucose levels [20].
The remainder of sources identified for inclusion in this review also recommended WBTI as positively supporting Indigenous communities. WBTI were shown to have the potential to be a useful tool for dieticians working to optimise the food and nutrient intakes of pregnant women [35] and may reduce sudden unexpected infant deaths by increasing education beyond traditional face-to-face delivery methods [26]. Research demonstrated the importance of designing culturally appropriate WBTI to promote health through understanding and use of natural resources [17], to increase ear health knowledge [40] and to improve asthma education [29].

Discussion
The purpose of this review was to identify and describe the available international scientific evidence on WBTI used by Indigenous peoples in Australia, New Zealand, Canada and USA for managing and treating health conditions. As mobile devices, including smart phones, become ubiquitous in the general population, web-based and other electronic interventions are increasing in number and scope. This is indicated by an increase in studies on the topic year on year, and of the many protocols that were excluded from this scoping review, but which clearly indicate a growing field with many studies planned or underway. The results indicate that while WBTI are most commonly designed to manage mental health and substance use issues, they are increasingly being incorporated in the range of treatment and support options for a variety of health conditions and are being used by those with the health condition or by service providers.
The popularity of WBTI stems in part from their potential reach, which extends to anyone in any geographical location or social context where they have access to the internet and a device capable of running the program. While increases in internet access amongst Indigenous populations in Australia, New Zealand, Canada and USA have been reported, in each of these countries, a "digital divide" across ethnic and geographical lines also exists, with Indigenous households and individuals having less access to the internet overall, and internet access being lowest in those geographical areas with the highest proportion of Indigenous residents [46]. The lack of any studies from Canada meeting the inclusion criteria was surprising, however there is evidence that other forms of ICT, such as telehealth, are in use in Canada, and that First Nations communities are engaging with and developing digital health technologies in line with Indigenous models of health and wellbeing [47].
The available data indicates that young people tend to have greater internet access and use [48] so it is perhaps not surprising that adolescents or young people were the focus of a large proportion of studies (8/34). Indigenous populations in Australia, USA, Canada and New Zealand are younger than the general populations in each country [46,[49][50][51], so interventions designed to improve the wellbeing of young people are particularly relevant. However, there were several studies of WBTI focusing on chronic diseases such as diabetes and cardiovascular disease that are relevant to older people.
Perhaps the most common and clear lesson articulated by study authors was the importance of developing programmes in collaboration with the target communities. In this sense, WBTI are no different to other interventions, with issues of governance and ownership being central not only to the ethical delivery of programmes but also to their acceptability, feasibility and effectiveness. Several authors cited "co-design" or collaborative design as strengths of their projects. Having the target community involved in all aspects of intervention and study design is in line with ethical guidelines for research with Indigenous peoples internationally [52][53][54][55].
Meta-analysis of effectiveness was beyond the remit of this scoping review, and while such analysis is likely to be limited by the small sample sizes evident in these studies, future research could usefully examine both the effectiveness and cost-effectiveness of WBTI with Indigenous people. Cost-effectiveness is frequently highlighted as an advantage of WBTI. However, few studies include analysis of cost-effectiveness that incorporates the often-substantial costs of development that may occur over lengthy time periods. This scoping review was limited in the degree to which it could examine barriers to accessing WBTI resulting from cultural and linguistic diversity, low health literacy, limited digital capabilities and infrastructural and resource limitations for individuals and communities in different geographic locations. This review is also based on a definition of health that is less holistic and relational than Indigenous models of health and wellbeing tend to be [1]. Future research could focus more explicitly on a broader range of social health factors, such as language use and reclamation, as these are likely to have health benefit from an Indigenous perspective [56]. Broadening the review to include digital sources, such as app stores and social media, could also provide a more comprehensive account of all indigenous-focused WBTI and tools, although formal evaluations of such interventions, which are the focus of this review, are unlikely to be sourced this way.
As mobile digital devices become cheaper and more widespread, and internet technology improves in speed and geographic coverage, it seems safe to assume that WBTI will also become more widespread, and of interest to health services and commercial entities who may wish to exploit potential markets. This is true for Indigenous peoples as it is for others, although the smaller population size may limit commercial interest in Indigenousspecific WBTI and explain the propensity of funding from government rather than commercial sources. As the field grows, ensuring that technologies accessed in Indigenous communities are high quality, evidencebased, culturally appropriate, inclusive and accessible will require that we continue to examine and re-examine the evidence as it emerges and that Aboriginal communities continue to lead the development of technologies that best meet their needs.
Additional file 1. Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist.