key: cord-0939846-cet2edxf authors: Gaborit, Lorane; Robinson, Melanie; Sutherland, Stewart title: Characterising health promotion in Aboriginal and Torres Strait Islander languages: A content analysis of COVID‐19 and maternal health resources date: 2022-03-31 journal: Health Promot J Austr DOI: 10.1002/hpja.595 sha: 56f89c74dbd3d63072c92a9083f4ea3f2a05a6e1 doc_id: 939846 cord_uid: cet2edxf ISSUE ADDRESSED: Health promotion resources in Aboriginal and Torres Strait Islander (Indigenous) languages are being widely translated and disseminated at the community, health service and government level. In addition to outlining the relevant Australian policy context and evidence base, this study sought to describe the availability and characteristics of COVID‐19 and maternal health promotion resources incorporating Indigenous languages. METHODS: Health promotion resources published online between June 2005 and June 2020 were identified by a desktop scan and screened against quality inclusion criteria. A content analysis by resource type, health topic, purpose, use of language and source was conducted. RESULTS: A total of 215 resources was eligible for inclusion, incorporating 50 different Indigenous languages and representing a varied approach to language use and health promotion. Almost 7 times as many COVID‐19 resources were identified than maternal health materials. CONCLUSIONS: In contrast to maternal health, COVID‐19 has seen a sharp rise in the number of health promotion resources produced in language, especially in formats capable of streamlined replication in multiple languages. Strong use of narrative, storytelling and alternative primary aims such as language education suggests potential for greater collaboration between health promotion organisations and other community groups and services. Bilingual resources may have applications for communities where traditional language knowledge is being reawakened. SO WHAT? Emerging capacity to efficiently produce health promotion resources in multiple Indigenous languages could be capitalised for health topics beyond COVID‐19. However, further research in determining best practice and user perspectives is essential in guiding the development of these resources. The latest National Agreement on Closing the Gap makes clear the failure of successive governments to correct disparities in health outcomes between Aboriginal and Torres Strait Islander (Indigenous) and non-Indigenous people. 1 Given persisting disparities, in recent years policy makers have placed an increased focus on innovative approaches to reducing health inequality, such as incorporating culture into health initiatives. 2 Emerging evidence indicates connection to traditional language and culture plays a protective role in fostering wellbeing and good health for Indigenous people, indirectly improving health outcomes such as rates of suicide and diabetes. [3] [4] [5] In Australia, research in this space has primarily focused on the current state of Indigenous languages, the importance of preserving languages in order to foster strong cultural identity, and the impacts of language reclamation programs on social and emotional wellbeing, an Indigenous holistic and whole-of life view of health. [6] [7] [8] [9] There is scope to consider the role of Indigenous languages in health promotion to provide avenues for directly improving health outcomes. In addition to traditional knowledge sharing, Indigenous languages have been incorporated into resources relating to a wide variety of health topics, such as maternal health, for many years now. However, the coronavirus disease 2019 (COVID-19) pandemic has also illustrated the capacity of organisations to rapidly produce and disseminate health promotion resources in Indigenous languages, with messages being translated and distributed within only months of the first recorded COVID-19 cases in Australia. 10 languages. To achieve our aim, we will identify publicly available maternal health and COVID-19 health promotion resources incorporating Indigenous languages, and characterise these resources by resource type, health topic, purpose, use of language and source. This study forms the first part of a multi-staged project which will aim to extend the work conducted in this study to explore health worker and user perspectives of resources in language and evaluate the impact of different approaches to the publication and dissemination of health promotion resources in language. A digital database of resources identified in this study will be made publicly available. Indigenous languages in Australia are undergoing a renaissance. Of more than 120 Indigenous languages still in use, at least 31 language varieties are currently being reawakened by communities in Australia. 12 Indigenous languages are still considered 'strong', meaning they are spoken by all age groups and acquired by children. 11 In the 2016 Australian census 63,754 people, or 10% of Aboriginal and Torres Strait Islander respondents, reported speaking an Indigenous language at home. Of the people who spoke an Indigenous language at home, 85% reported speaking English well or very well, while 11% reported they did not speak English well at all. 12 Statistics focused on language use 'at home' may be misleading, failing to account for individuals currently in the process of reclaiming knowledge of traditional languages, or communication difficulties that run deeper than language barriers alone. This includes misunderstandings rooted in differing culturally derived health concepts and worldview, the way groups of people categorise and conceptualise their cultural realities. 13 16, 17 In the media, discussion has also at times been marked by the argument that there Aboriginal and Torres Strait Islanders, culturally and linguistically diverse people, health equity, health literacy, health policy are 'too many' Australian Indigenous languages to support increased use in the public sector. 18, 19 The Closing the Gap Refresh consultation process identified language and culture as a priority area, and it has been allocated targets in the 2020 National Agreement on Closing the Gap. Formal evaluations of Indigenous health programs are limited in number and quality, and the need for better evaluation in this sector is well recognised. 25, 26 In the area of health promotion in Indigenous languages, the literature primarily consists of case reports, organisation-led assessments, and brief discussion within broader qualitative studies of culturally appropriate health materials. Anecdotal evidence from health professionals working with Indigenous communities indicates that oral education or information dissemination in the first language of the patient can counteract communication failures and information deprivation. 14, 27, 28 Illustratively, an early report of the Aboriginal Community Controlled Health sector response to the COVID-19 pandemic described how the creation and distribution of tailored and culturally appropriate resources, including those using Indigenous languages, was effective in delivering trusted health promotion and crisis communication across multiple platforms. 10 Public health awareness and education campaigns in other areas such as breast cancer screening have also incorporated Indigenous languages as an adjunct to other forms of health promotion. 29 Additionally, the literature finds that health promotion in language goes beyond solely the translation of messages, to also consider worldview, culturally-based teaching styles and visual aids. 27 Arnhem Land suggest messages in language are engaging, recognisable and acceptable to community. 30, 31 One report describes a family taking such ownership of this message as to place a Yaka Ŋarali sign on their home to show it was smoke free. 30 Despite not explicitly examining traditional Indigenous languages themselves, studies of culturally appropriate resources provide insights into the impacts and barriers to health promotion in language. For instance, the use of 'familiar colloquial language' in Indigenous health promotion resources contributes to improving the acceptability of message delivery. 32 The iconic safe-sex promoting 'Condoman' is a clear example of the impact of this use of Aboriginal English in health promotion, with the message 'Don't be shame be game -Use condoms' achieving high levels of recognition in Australia. 33 Not all findings have been so positive. Another study of resources using common Indigenous Australian terms such as mob and Elder found that despite the availability of culturally appropriate resources, health professionals participating in the study were unaware of their existence, potentially due to poor accessibility or ineffective dissemination techniques. 34 Indigenous health promotion research is increasingly recognising a desire for resources in language. In a study of the use of culturally appropriate educational flipcharts, carers identified a desire for flipcharts to be transcribed into language, specific to community. 35 In another study, participants overwhelmingly cited language as both the single most important feature of educational resources and the most significant barrier to effective communication. Participants perceived best-practice to be the removal of medical jargon, and the translation of plain English to local language using 'culturally safe' concepts, with a preference for an electronic format emphasising interactive pictures and less text unless in spoken and written local language. 28 The COVID-19 pandemic has had a disruptive impact on the Indigenous health sector. Recognition of the increased risk faced by Indigenous people due to higher rates of comorbidities, barriers to healthcare, and socio-cultural factors has led to mobilisation and action at all levels of community, government, and health organisations. Aboriginal Community Controlled Health organisations and their peak bodies developed health messages about COVID-19 even before the World Health Assembly declared COVID-19 a global pandemic in March 2020. 10 By contrast, maternal health has been a long-standing issue in Indigenous health. It is usually defined as the health of women before and during pregnancy, childbirth and the postpartum period. A particular emphasis should be placed on maternal health given the importance of early and continued engagement with antenatal care for longterm health outcomes. In our study, maternal health also incorporates broader aspects of women's health that may be applicable We identified COVID-19 and maternal health promotion resources in a desktop scan conducted in July 2020, using a search plan that incorporated five sources and the following quality inclusion criteria: 1. The resource is free and publicly available online, published in Australia between June 2005 and June 2020 inclusive. On reviewing the entire sample, a coding table was developed inductively by the primary investigator to capture a range of resource features and address the study aims (Table 1) . 38 All eligible resources were coded according to this coding table, to inform a content analysis of resources by resource type, health topic, purpose, use of language and source. The extent of incorporation of Indigenous languages varied greatly between health promotion resources ( Table 2 ). 10.7% of the identified resources limited use of language to a single word or phrase within a key element of the resource, such as the title (n = 23). For instance, a poster by Children's Ground using Arrernte used the message 'Alengele atneye (stand at a distance). My family are at risk from COVID-19'. 40 When such an approach to language was used, the word or phrase was mostly understandable across multiple languages and contexts. For instance, the Royal Women's Hospital's resource You and Your Boorai: Taking Care During Pregnancy described the use of the word 'boorai' (baby) as such: F I G U R E 1 Search plan for online review of COVID-19 and maternal health promotion resources incorporating Aboriginal and Torres Strait Islander languages, including search terms, sources, and eligibility criteria. Using this search plan 215 resources were identified for inclusion in the study We use the word boorai in this book, because it is common to many Aboriginal languages throughout Victoria. The book will be used by families from outside Victoria and we hope you understand the importance of using words that are meaningful to our local communities. 41 Similarly, an advertisement by Bega Garnbirringu Health Service used the slogan 'If you want a baby, are having a baby, or breastfeeding, wiya wama, no alcohol is the safest choice' to raise awareness of the dangers of drinking during pregnancy. 42 The phrase 'wiya wama' (no alcohol) is common across several Western Desert languages such as Pitjantjatjara and Ngaanyatjarra, however it was used in this advertisement without acknowledgement of a singular language. 43 89.3% of resources (n = 192) were entirely published in language, whether this be in a written, audio, visual or interactive format. In 40.9% of resources (n = 88), English translations were provided separately, for instance in the video description, and not directly integrated into the resource. Over a third of resources integrated their translation, such as by using English subtitles (n = 78). Two resources used subtitles in another language, such as Kriol. Month/ year when the resource was published. Where no month was provided, resources were coded as having been published in January of that year. Type of resource Resource media. Options: "visual" (video), "audio" (radio segment/ recording), "written" (book, booklet, brochure, flyer), "interactive" (mobile application, web application). Language group Australian Indigenous language used. Language was recorded from resource description or investigated where possible using Indigenous language dictionaries and contextual information. Use of language Number of words (or approximate percentage of the resource) incorporating Indigenous languages. Options: "full" (entirely in language), "partial" (approximately half the resource, excluding subtitles), "phrase" (1-2 sentences) or "word(s)" (1-5 words). Health area Health area addressed. Options: "maternal health" or "COVID-19". Topic addressed within maternal health or COVID-19. Determined from resource abstract/ description or content of resource itself. Name of resource publisher and/ or author. Determined from resource abstract/ description or content of resource itself. Type of source Subclassification of publisher. Options: "academic" (University or other educational institution), "ACCHO" (Aboriginal Community Controlled Health Organisation, such as an Aboriginal Medical Service), "ACCHO peak" (representative state or territory Aboriginal Community Controlled Health Organisation, or member of the Coalition of Peaks), "federal government", "state government", "Language service" (Organisation or centre based around Indigenous languages), "local government" (Land council, locallybased Aboriginal Corporation), "other Indigenous organisation" (Indigenous owned/ operated organisation not otherwise defined), "non-Indigenous organisation" (non-Indigenous owned/operated organisation not otherwise defined). Distinction between resources replicated into multiple different languages from an English template or tailored to the local context beyond language. Options: "not series" (not part of a series), "series -identical" (part of a series where resources are identical excluding language used), "series -not identical" (part of a series where resources are not identical). Presence of an English translation. Options: "no" (no translation), "yes separate" (translation provided separately, such as in another version of the resource), "yes integrated, excluding subtitles" (translation viewable while viewing the resource), "cues only" (translation limited to highly simplified essential information), "partly" (some translation provided), "subtitles", "translation in non-English language". Purpose of the resource. Options: "advertisement/ informative only", "documentary format", "narrative-based" (storytelling), "language education", "entertainment (such as music videos)". Narrative and storytelling were key components in almost 60% of maternal health visual and interactive resources (n = 10), and 37% of all maternal health resources ( Table 2) Approach to translation in a sample of 215 COVID-19 and maternal health promotion resources incorporating Indigenous languages, by approach and percentage of all resources. This chart, produced in Excel, illustrates the distribution of approaches to translation of resources using Indigenous languages between June 2005 to June 2020. Approach to translation is defined as follows to distinguish between resources replicated into multiple different languages from an English template or tailored to the local context: "Replicated resource (series)" refers to resources from a series of identical resources excluding language used, "Individualized resource (series)" refers to resources from a series of non-identical resources, and "Individualized resource (single)" refers to resources not part of a series. Approach to translation was determined by content analysis of the results of a desktop review As a result of this review, the authors make the following recommendations: 1. Indigenous health promotion resources must be developed and guided by Aboriginal and Torres Strait Islander communities. 2. Messages should be locally tailored, exclude medical jargon and use language that is recognisable and easy to understand. Torres Strait Islander artwork and cultural references. 4. Electronic formats should be used, as these allow for interactive pictures and oral narration, integrated use of English and facilitated distribution through social media. 5. The replication of a single resource into multiple versions, each translated into or incorporating a different Indigenous language, allows for cost-effective and rapid expansion of audience reach, which may be appropriate for health crisis messaging; however, it should be noted that this may also come at the cost of incorporating local community input and cultural safety principles. 6. The use of only single words or phrases in language within a resource must not be seen as insufficient and may increase the ac- The authors declare no conflict of interest. The Closing the Gap (CTG) refresh: should Aboriginal and Torres Strait Islander culture be incorporated in the CTG framework? How? 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