Cardiovascular Epidemiology Research Centre, School of Population and Global Health, The University of Western Australia, Stirling Highway, Nedlands, Perth, WA, 6009, Australia.
School of Medical and Health Science, Edith Cowan University, Perth, Australia.
BMC Health Serv Res. 2024 Aug 20;24(1):946. doi: 10.1186/s12913-024-11390-5.
Healing Right Way (HRW) aimed to improve health outcomes for Aboriginal Australians with stroke or traumatic brain injury by facilitating system-level access to culturally secure rehabilitation services. Using a stepped-wedge randomised controlled trial (RCT) design (ACTRN12618000139279, 30/01/2018), a two-pronged intervention was introduced in four rural and four urban hospitals, comprising 1.Cultural security training (CST) for staff and 2.Training/employment of Aboriginal Brain Injury Coordinators (ABIC) to support Aboriginal patients for 6-months post-injury. Three-quarters of recruited patients lived rurally. The main outcome measure was quality-of-life, with secondary outcomes including functional measures, minimum processes of care (MPC); number rehabilitation occasions of service received, and improved hospital experience. Assessments were undertaken at baseline, 12- and 26-weeks post-injury. Only MPCs and hospital experience were found to improve among intervention patients. We report on the process evaluation aiming to support interpretation and translation of results.
Using mixed methods, the evaluation design was informed by the Consolidated Framework for Implementation Research. Data sources included minutes, project logs, surveys, semi-structured interviews, and observations. Four evaluation questions provided a basis for systematic determination of the quality of the trial. Findings from separate sources were combined to synthesise the emerging themes that addressed the evaluation questions. Three components were considered separately: the trial process, CST and ABIC.
The complex HRW trial was implemented to a satisfactory level despite challenging setting factors, particularly rural-urban system dynamics. Patient recruitment constraints could not be overcome. The vulnerability of stepped-wedge designs to time effects influenced recruitment and trial results, due to COVID. Despite relatively high follow-up, including to rural/remote areas, data points were reduced. The lack of culturally appropriate assessment tools influenced the quality/completeness of assessment data. The ABIC role was deemed feasible and well-received. The CST involved complex logistics, but rated highly although online components were often incomplete. Project management was responsive to staff, patients and setting factors.
Despite mostly equivocal results, the ABIC role was feasible within mainstream hospitals and the CST was highly valued. Learnings will help build robust state-wide models of culturally secure rehabilitation for Aboriginal people after brain injury, including MPC, workforce, training and follow-up.
“正确康复之路”（Healing Right Way，HRW）旨在通过促进系统层面获得文化安全的康复服务，改善澳大利亚原住民中风或创伤性脑损伤患者的健康结果。该研究采用了一种逐步楔形随机对照试验（RCT）设计（ACTRN12618000139279，2018 年 1 月 30 日），在四所农村医院和四所城市医院实施了两项干预措施，包括 1. 员工文化安全培训（Cultural security training，CST）和 2. 培训/雇佣原住民脑损伤协调员（Aboriginal Brain Injury Coordinators，ABIC），以在受伤后 6 个月内为原住民患者提供支持。四分之三的入组患者居住在农村。主要结局指标是生活质量，次要结局指标包括功能测量、最低护理流程（Minimum processes of care，MPC）；接受康复服务的次数，以及改善医院体验。评估在受伤后 12 周和 26 周进行。只有干预组患者的 MPC 和医院体验有所改善。我们报告了过程评估，旨在支持对结果的解释和翻译。
使用混合方法，评估设计依据的是实施研究综合框架。数据来源包括会议记录、项目日志、调查、半结构化访谈和观察。四个评估问题为系统确定试验质量提供了基础。从不同来源收集的结果进行了组合，以综合出现的主题，以解决评估问题。分别考虑了三个部分：试验过程、CST 和 ABIC。
尽管面临着具有挑战性的环境因素，特别是城乡系统动态因素，HRW 试验还是以令人满意的水平实施。患者招募的限制无法克服。由于 COVID，逐步楔形设计对时间效应的敏感性影响了招募和试验结果。尽管包括对农村/偏远地区的随访相对较高，但数据点减少了。缺乏文化上适当的评估工具影响了评估数据的质量/完整性。ABIC 角色被认为是可行的，并且受到了好评。CST 涉及复杂的后勤工作，但尽管在线部分通常不完整，但评价却很高。项目管理对员工、患者和环境因素做出了反应。
尽管结果大多模棱两可，但 ABIC 角色在主流医院中是可行的，CST 受到高度重视。经验教训将有助于建立针对原住民脑损伤后文化安全康复的强大的州级模型，包括最低护理流程、劳动力、培训和随访。
