It is widely known that improving the quality of healthcare is one of the most direct ways to address the significant health disparities between Aboriginal and Torres Strait Islander peoples and Australians of other descent. In 2008, the Council of Australian Governments (COAG) committed to ‘work together to achieve equality in health status and life expectancy between Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians by the year 2023’(1) (Hereafter, we use “Aboriginal” as a collective term, acknowledging the diversity of language and culture of Aboriginal and Torres Strait Islander peoples, as the First People and custodians of Australia). A core component of COAG’s ‘Closing the Gap’ strategy were measurable targets to monitor improvements in the health and wellbeing of the Aboriginal population. In response, there has been a rapidly expanding quest for information, reflected in a proliferation of quality improvement programs and introduction of key performance indicator (KPI) reporting (2). In the Northern Territory, for example, gaps in quality of Aboriginal primary health care were identified following the introduction of Aboriginal Health Key Performance Indicators and performance reporting systems. These findings informed the Northern Territory’s continuous quality improvement strategy, which has been credited not only for its sustained use, but for the value of its data in strengthening health systems and improving quality of health care for Aboriginal peoples (3).
Reports on health care quality and health system performance, however, repeatedly lack information about Aboriginal health promotion programs. For example, health promotion - described as ‘activities designed to improve or protect health within social, physical, economic and political contexts’- is one of 68 performance measures included in the Australian Government’s Aboriginal and Torres Strait Islander Health Performance Framework (4). Reporting on this measure is based on the number of health promotion interventions provided by clinicians and other health professionals. Information that could be used to monitor quality of Aboriginal health promotion is lacking. Cited reasons for this include suitability of indicators to measure and monitor quality, and limitations in data availability and quality (4).
In addition to improving reporting of the contribution that Aboriginal health promotion makes to ‘closing the gap’, there are calls for Aboriginal people and communities to become active partners in their health care delivery (5, 6). COAG’s most recent Closing the Gap report makes stronger assertions to increase meaningful partnerships between all levels of governments and communities, in recognition that work to date is insufficient for meeting 2023 targets (7). Studies evaluating Aboriginal people’s participation in health promotion have consistently concluded that community involvement enhances delivery and uptake of health programs (8-11). However, the value of health promotion has yet to be fully realized because there remains insufficient evidence to confidently determine the impact on Aboriginal health and wellbeing (10,11). It has been suggested that by improving documentation of community participation strategies and processes, more successful strategies could be identified and replicated, thus strengthen the evidence base (10,11).
Health information systems (HIS) have the potential to capture and share data that could improve quality and reporting of Aboriginal health promotion, including details of community participation. Firstly, by facilitating collection, documentation and organization of a vast array of information about health promotion in a structured and systematic way. Secondly, as a source of data to be analyzed and communicated in real-time for quality improvement and performance indicator reporting purposes. A HIS commonly used in hospitals and medical services is the Electronic Medical Record (EMR). EMRs, digital versions of the patient chart, contain information about patient medical and treatment history collected by and for clinicians, usually within a single healthcare institution. EMRs are valuable sources of data that providers can use in making decisions about health care delivery. Indeed, health services have sought innovative ways to utilize these data to report on and improve the quality health care and health system performance for Aboriginal Australians (12, 13). EMRs and many other health information systems, however, are rarely designed or developed to capture, store or retrieve data about population-level services and activities. Currently, there is some evidence to suggest that health promotion and prevention could similarly benefit from health information systems (14, 15). Yet, to our knowledge, there is no research on the potential use of these systems in the context of Aboriginal health promotion. Research into such technologies is challenging because HIS for recording and monitoring health promotion efforts are often created for individual organization’s internal purposes, without any public record of how it was designed, used or lessons learned (16).
Within this broader context, we report a study of Australia’s first investigation of a HIS designed for recording and storing information about Aboriginal health promotion. The Quality Improvement Program Planning System (QIPPS) was an innovative and unique online, project planning and evaluation system for health promotion and community development projects. From 2008 until 2019, when QIPPS was decommissioned and no longer available on the market, it was the centralized online system for recording information about health promotion programs delivered by Northern Territory Health (NT Health). We were interested in the feasibility of utilizing this information to report on the quality of Aboriginal health promotion. Specifically, our aims were to extract data stored in QIPPS to describe: (1) the scope of Aboriginal health promotion programs; (2) the quality of Aboriginal health promotion program planning, delivery and evaluation; and (3) community participation strategies and processes used in Aboriginal health promotion, using chronic disease prevention activities as exemplars programs. Thereby, we identify the benefits and limitations of HIS’ for health promotion and potential for secondary uses of stored data for quality improvement purposes.
Study Context
The Northern Territory (NT) is arguably Australia’s most challenging health service delivery environment. The NT has the highest proportion of Aboriginal Australian residents compared to other states in Australia. Approximately 30% of the total NT population identify as being Aboriginal peoples compared to 3% of the total Australian population (17), making NT Health the single largest provider of health services to Aboriginal peoples in Australia. About 90% of the NT Aboriginal population live in discrete, remote communities, where the delivery of health care is logistically challenging, hence more expensive, than in urban settings (18). The gap in life expectancy between Aboriginal peoples and Australians of other descent is greater in the NT (14.4yrs for both males and females compared to 10.6 years for males and 9.5 years for females, nationally), and is increasing over time (1). The cost of the Aboriginal health gap in the NT has been estimated at $16.7 billion (20).
The NT Aboriginal population experience a disproportionate burden of chronic disease linked to inactivity, diet, socio-economic disadvantage and access to primary health care services (19). NT Health - the public healthcare system responsible for delivering clinical, primary health care and public health services to all Territorians – recognizes the critical role of health promotion and prevention in addressing these inequities and improving Aboriginal health outcomes. Health promotion is an ongoing strategic priority of NT Health (18, 22) and a core function in models of comprehensive primary health care (21). However, in reality, a range of challenges influence health promotion delivery and its success in the NT, including the burden of acute care in Aboriginal communities, high workforce turnover, low stability and acute-oriented, temporary staffing (19, 23) together with the availability of information about, and capacity to report on, health promotion quality and effectiveness (10, 23, 24).
To overcome some of these challenges, NT Health has introduced over the past 10 years a range of initiatives. These have included: (i) a Health Promotion Strategic Framework (25); (ii) introduction of the Quality Improvement Program Planning System (QIPPS); and (iii) participation in continuous quality improvement initiatives (26), including in health promotion specifically (27). These initiatives have proved useful in guiding planning and implementation of health promotion programs across the NT’s diverse context, and there is some evidence of impact on health promotion quality (10, 24). Previous assessments, however, have mainly been conducted at a community-level. There remains limited knowledge on the extent to which these initiatives are meeting Territory-wide strategic health promotion goals.