Health and JusticeMunro et al. Health and Justice (2017) 5:12 DOI 10.1186/s40352-017-0056-z

STUDY PROTOCOL Open Access

The development of a healing model ofcare for an Indigenous drug and alcoholresidential rehabilitation service: acommunity-based participatory researchapproach

Alice Munro1* , Anthony Shakeshaft1 and Anton Clifford1,2

Abstract

Background: Given the well-established evidence of disproportionately high rates of substance-related morbidityand mortality after release from incarceration for Indigenous Australians, access to comprehensive, effective andculturally safe residential rehabilitation treatment will likely assist in reducing recidivism to both prison andsubstance dependence for this population. In the absence of methodologically rigorous evidence, the delivery ofIndigenous drug and alcohol residential rehabilitation services vary widely, and divergent views exist regarding theappropriateness and efficacy of different potential treatment components. One way to increase the methodologicalquality of evaluations of Indigenous residential rehabilitation services is to develop partnerships with researchers tobetter align models of care with the client’s, and the community’s, needs. An emerging research paradigm to guidethe development of high quality evidence through a number of sequential steps that equitably involves services,stakeholders and researchers is community-based participatory research (CBPR). The purpose of this study is toarticulate an Indigenous drug and alcohol residential rehabilitation service model of care, developed incollaboration between clients, service providers and researchers using a CBPR approach.

Methods/Design: This research adopted a mixed methods CBPR approach to triangulate collected data to informthe development of a model of care for a remote Indigenous drug and alcohol residential rehabilitation service.

Results: Four iterative CBPR steps of research activity were recorded during the 3-year research partnership. As adirect outcome of the CBPR framework, the service and researchers co-designed a Healing Model of Care thatcomprises six core treatment components, three core organisational components and is articulated in two programlogics. The program logics were designed to specifically align each component and outcome with the mechanismof change for the client or organisation to improve data collection and program evaluation.

Conclusion: The description of the CBPR process and the Healing Model of Care provides one possible solutionabout how to provide better care for the large and growing population of Indigenous people with substance.

Keywords: Indigenous drug and alcohol residential rehabilitation, Criminal justice system, Community-BasedParticipatory Research, Remote, Model of care, Research partnerships

* Correspondence: a.munro@unsw.edu.au1National Drug and Alcohol Research Centre, University of New South Wales,Sydney, NSW 2052, AustraliaFull list of author information is available at the end of the article

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made.

Munro et al. Health and Justice (2017) 5:12 Page 2 of 12

BackgroundThe aetiology of the harmful effects of substance misuseon Indigenous Australians is a complex range of factorsincluding the intergenerational impacts of colonisationand subsequent high rates of incarceration, suicide, self-harm and poverty (Wynne-Jones et al., 2016; Marmot,2011; Productivity Commission, 2016; DoHA, 2013;ACOSS, 2016). Indigenous Australians comprise approxi-mately 3% of the Australian population (ABS, 2014), anddrug and alcohol-related morbidity and mortality are dis-proportionately higher among this population (AIHW,2011; AIHW, 2016). In order to further reduce rates ofsubstance misuse harms, more effective prevention andtreatment programs that are tailored to the specific needsof Indigenous Australians are required.Indigenous drug and alcohol residential rehabilitation

services are a preferred option for Indigenous peoplewho have high levels of substance dependence, primarilybecause they provide a culturally acceptable form oftreatment (Brady, 1995; Chenhall & Senior, 2013). Inaddition to being culturally acceptable, Indigenousresidential rehabilitation services are typically multi-component, reflecting the complex social, economic,housing, mental health, crime and legal challengesexperienced by their clients (Wilson et al., 2017;Honorato et al., 2016; Leal et al., 1998; Farabee & Shen,2004; Brunette et al., 2004; Mortlock et al., 2011;Weatherburn, 2008). A current analysis of the charac-teristics of clients admitted to a remote Indigenousresidential rehabilitation service in NSW, Australia, forexample, highlighted the strong correlation betweentheir significant health and socio-economic needs, andtheir involvement in the criminal justice system (Munroet al., 2017, under review). This analysis not onlyshowed that the majority of clients were referred fromthe criminal justice system, but that this proportionhad statistically significantly increased over time, from79% in 2011/12 to 96% in 2015/16. Most clients had atleast two co-occurring risk factors, in addition to acriminal history: 69% self-reported polysubstance use(primarily methamphetamines, alcohol and cannabis)and 51% reported a current mental illness (primarilydepression, anxiety and bipolar disorder). The statisti-cally significant growth in clients referred from thecriminal justice system is consistent with the reported77% increase in adult Indigenous prisoners in Australiafrom 2000 to 2015 (Productivity Commission, 2016)and the disproportionately high prevalence of substancemisuse among prisoners, which has been identified as akey driver in the disproportionately high incarcerationrate (Weatherburn, 2014; Indig et al., 2010; Doyle et al.,2015; NIDAC, 2014; Weatherburn, 2008).Given the well-established evidence of disproportion-

ately high rates of substance-related morbidity and

mortality after release from incarceration (Kinner et al.,2011), access to comprehensive, effective and culturallyappropriate residential rehabilitation treatment will mostlikely assist in reducing recidivism to both prison andsubstance abuse for Indigenous Australians (NIDAC,2014; Kinner & Wang, 2014; Heffernan et al., 2016). The2015–16 Aboriginal and Torres Strait Islander OnlineServices Report (OSR) from Australia, however, identi-fied a number of gaps in current service provision, par-ticularly in relation to addressing the mental health andthe social and emotional wellbeing needs of Indigenousclients (AIHW, 2017). Further, despite the need to estab-lish the relative effectiveness of different configurationsof culturally acceptable, multi-component treatmentsdelivered in Indigenous residential rehabilitation ser-vices, a current systematic review of studies of Indigen-ous residential rehabilitation services from Australia, theUnited States, Canada and New Zealand, published be-tween 2000 and 2016, identified only one quantitativeevaluation (James et al., 2017, under review). This find-ing is consistent with results from a recent bibliometricreview of published literature from the Indigenous drugand alcohol field generally, which found evaluations repre-sented only 11% of published research in the past twentyyears for Australia, the United States, Canada and NewZealand (Clifford & Shakeshaft, 2017). These reviews em-phasise the need for more rigorous evaluations ofIndigenous drug and alcohol services, including residentialrehabilitation treatment.In the absence of sufficient evidence from quantitative

evaluation studies about the most cost-effective configu-rations of multi-component treatments, approaches tothe delivery of Indigenous residential treatment pro-grams vary widely, and divergent views exist regardingthe effectiveness and appropriateness of different poten-tial treatment components. As such, specific, evidence-based features of Indigenous residential programs arenot well defined (James et al., 2017, under review;Chenhall & Senior, 2012; Chenhall & Senior, 2013; Gone& Calf, 2011; Taylor et al., 2010). One way to increasethe quantity and methodological quality of evaluationsof Indigenous residential rehabilitation services is todevelop collaborative partnerships between services andresearchers, to work together to develop models of carethat synthesise the views of clients and service providerswith existing research evidence, including both descriptivedata and evaluations of treatment outcomes (Shakeshaftet al., 2012). Identified as a key priority in the 2014–19National Aboriginal and Torres Strait Islander PeoplesDrug Strategy (NDS, 2015), such partnerships couldsimultaneously co-create new knowledge and optimiseclient outcomes by embedding the development andevaluation of treatment models into the routine deliv-ery of services. The purpose of this study is to report

Munro et al. Health and Justice (2017) 5:12 Page 3 of 12

on the articulation of a model of care for an Indigenousdrug and alcohol residential rehabilitation service, de-veloped in collaboration between clients, service pro-viders and researchers.

MethodsEthics approval and consent to participateEthical approval was sought and granted by the AboriginalHealth and Medical Research Council (1023/14) and theUniversity of New South Wales Human Research EthicsCommittees (HC14142).

Setting and clientsThis study was undertaken with Orana Haven Aboriginaldrug and alcohol residential rehabilitation service (OH),which is located in NSW, approximately 700 km north-west of Sydney (in relation to OH, the word Aboriginal isused because it is recommended by the Aboriginal Healthand Medical Research Council as being most appropriatefor the Indigenous peoples of NSW). The service beganoperating as an Aboriginal Community Controlled HealthOrganisation (ACCHO) in 1983. OH’s current visionbuilds on this long history of Aboriginal community-control, and that is to “provide a culturally safe drug andalcohol healing centre that maximises the strengths ofAboriginal people and communities” (OH 2015–2018Strategic Intent, Supp. 1). Based on a combination of aTherapeutic Community and 12-Step treatment approach,OH offers a 3-month voluntary rehabilitation program forAboriginal males, 96% of whom were referred from thecriminal justice system in 2015/16. OH has an average of66 client admissions annually, of whom 85% identify asAboriginal. Mean length of stay is 56 days, although athird (36%) discharge within the first month. An estimated32% of clients complete the program, 47% self-dischargeand 20% are house-discharged for failing to comply with

Fig. 1 The community-based participatory research (CBPR) approach for O

treatment requirements, such as providing continu-ously clean urine samples. OH’s completion rate of32% is comparable to the 34% reported for non-Aboriginal residential rehabilitation services in Australia(Darke, Campbell & Popple, 2012), but it is possible thiscould be improved given the 62% completion rate re-ported in another study (Sung, Belenko & Feng, 2001).Due to inconsistent reporting across Indigenous residen-tial rehabilitation services, rates of self-discharge couldnot be reliably compared with OH’s average of 47% of allclients.

Study designThis 3-year (2014–2017) study used a community-based participatory research (CBPR) approach. CBPRis an emerging transformative research paradigm de-signed to bridge the gap between science and practicethrough community or service provider engagementthroughout the research process, to achieve socialchange (Lazarus et al., 2014; Windsor, 2013; Waller-stein & Duran, 2006). The process of CBPR typicallyinvolves cycles of collaborative action, often in se-quential steps that engage community or service pro-vider participants as co-researchers, educating andempowering them to effect positive changes in theirenvironment (Kowanko et al., 2009; Windsor, 2013;Lazarus et al., 2014). Given CBPR does not outline aspecific and rigorous methodology, however, Windsor(2013) proposes the addition of mixed scientificmethods to ensure adequate rigor in the productionof new knowledge. In the context of Indigenous health,CBPR has been shown to be highly culturally acceptable(Mooney-Somers & Maher, 2008; Cochran et al., 2008;Pyett, 2002; Snijder et al., 2015). As visually representedin Fig. 1, the CBPR framework designed for this studycomprised four iterative steps.

rana Haven

Munro et al. Health and Justice (2017) 5:12 Page 4 of 12

Step 1: Effective engagement (March 2014 - October 2014)The activities that facilitated effective engagement were:

i) A formal invitation from OH’s Board of Directors tothe National Drug and Alcohol Research Centre(NDARC) to form a partnership. In 2014, OHreceived federal funding to evaluate their treatmentprogram and undertake capital works. The fundingprovided scope for OH to independently engagewith experts and, consequently, OH’s Board ofDirectors invited the National Drug and AlcoholResearch Centre (NDARC) to partner with them toreview their treatment program.

ii) An initial meeting between the OH Board andNDARC researchers to define the scope of theproposed evaluation and the principles of thepartnership. It was agreed that this meeting shouldbe face-to-face, held on OH’s premises (toaccommodate the clinical and administrativeprocesses of OH and provide an opportunity forresearchers to tour the service), and involve senioracademics (professorial level) and junior researchersto reflect the seniority of OH’s Board membership.

iii)The joint development of a set of guiding principlesfor the partnership. These principles were furtherdeveloped and agreed subsequent to the initialmeeting, and were designed to be consistent withthe National Health and Medical Researchguidelines (NH&MRC, 2003) and the AustralianInstitute of Aboriginal and Torres Strait IslanderStudies Guidelines for Ethical Research inIndigenous Studies (AIATSIS, 2012):

1. Mutual recognition that meaningful change takestime. Consistent with the CBPR approach withIndigenous communities, both NDARC and OHallowed considerable project lead-time tounderstand the strengths and expertise from bothsides of the partnership and build mutual trust.

2. Regular, scheduled meetings. Both partnersagreed that good communication is thefoundation for a successful, long-term researchpartnership. As such, an agreed schedule of visitsto the OH service, meetings with the Board ofDirectors and regular teleconferences with keystakeholders and community leaders wasimplemented so that researchers and OHstakeholders had open dialogue about theresearch process.

3. The research activity should be closely tied toOH’s strategic planning needs and make asignificant contribution to new knowledge. Thisprinciple ensured that the research was beneficialfor both OH and the researchers.

4. Sharing ownership over the project. In recognitionof OH’s co-leadership of the research process,site-visits were specifically organised to be flexibleand responsive to the demands of the service andBoard members (especially when unexpectedcultural obligations occurred), rather than only theschedules of the researchers. It was also acceptedby the OH Board that formal researchrequirements (such as ethics approvals) werelengthy processes and needed realistic timeframes.

Step 2: Identifying the scope of the research (November2014 – September 2015)The activities that determined the specific nature of theresearch questions were:

i) NDARC researchers agreed to assist OH develop itsstrategic intent for 2015-2018. OH invited theresearchers to assist them in developing theirstrategy to meet the National Safety and Quality inHealth Care (NSQHC) Standards, which was closelyaligned with the revision of OH’s strategic plan. Theresearchers considered this was a unique opportunityto: i) better understand the service’s specific needs; ii)deepen the process of engagement and trust, asoutlined in Step 1; and iii) apply robust researchmethods to create rigorous new knowledge thatwould both inform OH’s strategic plans and engenderpublications for the peer-reviewed, academicliterature. The strategic planning process involvedconducting two focus groups, between May-July 2015,with OH staff and the Board of Directors. Data fromthe focus groups were analysed using thematicanalysis, which identified three strategic priorities: 1)strong governance and sustainability; 2) supportedand skilled staff; and 3) effective, culturally safe servicedelivery. The 2015-2018 Strategic Intent waspresented to the Board for feedback and subsequentapproval in September 2015, and supported OH’ssuccessful NSQHC accreditation in November 2015.

ii) Generating a clear research protocol for ethicsapproval. Researchers and OH staff workedcollaboratively to co-design the detailed mixed-methods research protocol. The purpose of thisprotocol was to obtain clarity and agreement aboutthe required research methods for approval by theOH Board, the local ACCHOs and the appropriateresearch ethics committees. This process required 12months to complete.

Step 3: Collection, analysis and interpretation of the data(October 2015 – October 2016)Quantitative data Researchers worked in partnershipwith OH staff to collect, analyse and interpret client and

Munro et al. Health and Justice (2017) 5:12 Page 5 of 12

service data collected at OH during a 5-year period from1 May 2011 to 30 April 2016. Two processes for collect-ing quantitative data were implemented at OH. First, cli-ent details were hand-written into a service admissionbook upon intake and discharge. Data collected included:demographics; referral type; and service utilization charac-teristics (e.g. type of discharge, length of time in treat-ment). Second, after a recommendation from researchersto obtain additional client information to inform servicedelivery, OH staff took the initiative to develop and imple-ment a phone assessment form from 2015 to 2016 to bet-ter understand the health, psychological and social statusof clients admitted to the service. Data collected included:previous rehabilitation service experience; previous andcurrent legal history; drug and alcohol history; current in-come; and current physical (e.g. asthma, diabetes) andmental health diagnoses (e.g. bipolar disorder, depression).As this self-report phone assessment was a service-designed tool, no validation of this measure has beenundertaken. A combination of this baseline data wasanalysed to better understand client characteristics andimprove local decision-making to better tailor the serviceto client needs and has been published elsewhere (Munroet al. 2017, under review). Preliminary results were fed-back to OH staff at two separate Board meetings (inFebruary and August 2016) to facilitate collaborativeinterpretation of the data to ensure outcomes wereclinically meaningful.

Qualitative data Researchers adopted purposive sam-pling (Barbour, 2001) to conduct a total of 21 in-depth,semi-structured interviews with OH nine staff andtwelve clients. The semi-structured interviews used‘yarning’ approach, a form of culturally respectful con-versation that is relaxed, narrative-based and emphasisesthe value of storytelling (Bessarab & Ngandu, 2010).Interviews were conducted across two phases (<3 monthsapart) to ensure qualitative data was captured at differ-ent time intervals. Interviews were conducted by a fe-male non-Aboriginal researcher (AM) at OH, weredigitally recorded, and later transcribed by an externaltranscriber to minimise researcher bias. Interview datawere analysed using Interpretative PhenomenologicalAnalysis (IPA) methodology, the findings of which arepublished elsewhere (Munro et al., 2017, under review).

Step 4: Feedback of final results (November 2016 – June 2017)A dissemination process of the final results from thecurrent CBPR study occurred in two ways. First, the pri-mary author and a senior Aboriginal drug and alcoholworker from OH had the opportunity to co-present find-ings at the 2016 National Indigenous Drug and AlcoholConference (NIDAC), the most notable Indigenous drugand alcohol conference in Australia. The value of OH as

a culturally safe and effective treatment service in re-mote Australia was recognised by OH being presentedwith the NIDAC Service Recognition Award. Inaddition, a senior OH staff member was also recognisedfor their years of service at OH with the NIDAC RemoteMale Worker Award. Second, final reports were pre-sented for feedback and subsequent approval at two sep-arate OH Board meetings in April 2017 and June 2017,thus completing Step 4 of the CBPR process.

ResultsA triangulation of the following sources of data informedthe Healing Model of Care described in the results: i)Focus groups; ii) Quantitative data; and iii) Qualitativedata. First, the focus groups identified key strategic pri-orities for OH in addition to the need for strong andtransparent governance. Second, the quantitative dataidentified the most prevalent client characteristics, towhich the Healing Model of Care ought to be tailored:clients were mostly Aboriginal men, all had multiple riskfactors, were mostly referred from the criminal justicesystem, and were mostly aged from 26 to 35. Third, thequalitative data identified the importance of a structuredprogram, the value of therapeutic relationships and thecritical importance of healing by immersion in Aborigi-nal culture and being on traditional “country.” The term“country” is often used by Australian Indigenous peopleto describe the complex and interrelated connections tofamily origins in Australia and the Torres Strait (QSA,2008). This includes the geographical region where aperson’s family is from and their connections to this re-gion and its people.

Healing Model of CareThe Healing Model of Care is comprised of thefollowing:

1. Core components of OH, as summarised in Fig. 2and detailed in the text below; and

2. OH treatment and organisational program logics, assummarised in Tables 1 and 2.

Core components of OHFigure 2 delineates two broad areas of OH’s service de-livery. First, the two centre circles represent the six coretreatment components. Second, the black outer circlerepresents the core three organisational components.The central component of OH’s treatment service deliv-ery is healing through culture and country, which is whyit is shown in the centre of Fig. 2. The other five coretreatment components enable healing through cultureand country, shown in the middle section of Fig. 2, andincludes: therapeutic activities; case management; lifeskills; time out from substances; and aftercare support.

Fig. 2 Core components of Orana Haven

Munro et al. Health and Justice (2017) 5:12 Page 6 of 12

The effective delivery of these treatment components isdependent upon the three core organisational compo-nents, as shown in the outer circle of Fig. 2: governance,rules and routine; staff skills; and links with services andnetworks. A detailed description of these components isprovided below.

Healing through culture and country There are anumber of activities that operationalise the centrality ofhealing through culture and country, and that are uniqueto Aboriginal services: the way clients and staff talk toeach other; the perception of family; the emphasis oncountry/mob/where you come from; the value of role-modelling positive behaviour; and the lived experiencefrom Aboriginal Elders or senior staff. OH recognisesthat healing is not just related to the wellbeing of theindividual, but also the wellbeing of the broadercommunity, thus acknowledging the interconnectednessbetween social, cultural, spiritual and environmental in-fluences of health. These elements are embodied in thered centre of the circle because they are applied acrossall of the other five core treatment components.

Case management The collaborative process of assess-ment, planning, facilitation and advocacy to meet an in-dividual’s holistic needs, or case management, is animportant component to all residential rehabilitationservices. In an Aboriginal residential rehabilitation con-text, case management must also ensure robust partner-ships with ACCHOs.

Therapeutic activities The range of therapeutic activitiesimplemented at OH comprises individual counselling

(predominantly motivational interviewing and cognitivebehaviour therapy), in addition to daily psychoeducationalgroups and weekly 12-Step meetings. Aboriginal-specifictherapeutic activities are embedded into program deliveryvia informal, ad hoc conversations or “yarns” that focus onidentity, personal spirituality, an individual’s connection tocountry, and the value of relationships.

Life skills To ensure clients lead meaningful lives whenthey return to families and communities, they are encour-aged to strengthen a range of life skills. Life skills devel-oped or re-established during treatment aims to foster astronger sense of self through kinships, cultural connec-tion, developing a consistent routine and enhancing per-sonal responsibility from learning work-ready skills.

Time out from substances Time out from substancesrefers to a client’s time away to recuperate from usingand/or the interactions with people who encouraged ormaintained their substance misuse. Time out from sub-stances therefore aims to provide a client with the timerequired to focus on improving their physical, mentaland spiritual health, largely through developing alterna-tive activities to substance misuse during spare time inpreparation for discharge. For instance, being on countryor near the river was identified as a key activity that epit-omises this core treatment component.

Aftercare support Aftercare support aims to provideongoing support tailored to the client’s needs, allowingfor flexibility to “step up” or “step down” to OH or otherservices, as required. Maintaining a client’s wellbeingafter discharge is currently enacted through ongoing re-lationships with OH staff or linking clients with servicesand AA groups in their community prior to discharge.

Links with services and networks Links with servicesand networks is core to OH program delivery as formany clients, as this may be their only point of contactwith the health care system. Therefore, links with ser-vices to support a client’s physical and mental healthneeds during treatment is a priority, alongside maintain-ing parole conditions or supporting clients to undertakewithdrawal prior to admission. Broader professionalnetworks across the drug and alcohol residential re-habilitation sector is also important to ensure OH is notisolated from integral knowledge exchange with compar-able services, despite its remote geographic location.

Staff skills OH staff must be client-centred, flexible andcommitted to improving the quality of lives of clientsadmitted to the service. Therefore, OH strives to employcombination of predominantly local Aboriginal staff witha mix of lived experience and formal qualifications. Staff

Table

1Orana

Haven

Treatm

entProjectLogic

a.Client

areasof

need

b.Interven

tion

c.Mechanism

sof

change

d.Processmeasures

e.Outcomes*

Coretreatm

ent

compo

nents

Flexibleactivities

Prim

aryclient

areasof

need

:Healingthroug

hcultu

reandcoun

try

-Beingon

coun

try/spiritualty

Reconn

ectin

gclientsto

cultu

reandcoun

try

viaactivities

andstrong

relatio

nships

No.of

clientsen

gage

din

regu

larcultu

ralactivities

Prim

aryou

tcom

es:

1.Riskysubstanceuse

1.Redu

cedsubstancemisuse

(AUDIT*/IRIS*cleanurines*)

-Develop

ingkinships

-Makingartefacts,fishing

bush

med

icine

2.Po

orqu

ality

oflife

Case

managem

ent

-Referralsto

localh

ealth

services

andvisitin

gspecialists

Clientsen

gage

din

theprog

ram

viapo

sitive

therapeutic

alliancebe

tweenstaffandclients

No.of

clientsstayingin

the

prog

ram

for3or

moremths

2.Increasedqu

ality

oflife

(WHOQoL-BREF*)

3.Po

orcultu

ral

conn

ectio

n3.Increasedconn

ectio

nto

cultu

re(GEM

*)-Working

with

correctio

nsReferralsto

AMSto

externalhe

alth

and

othe

rsocialservices

No.of

Indige

nous

Health

Che

cks/othe

rreferrals

-Fileno

tes/assessmen

ts

-Client

transport

No.of

kmsof

transport

Second

aryclient

areasof

need

:Therapeutic

activities

-One

-on-on

ecoun

selling

Improvingclient

quality

oflife

No.of

clientsmaintaining

abstinen

ce3mon

thspo

stdischarge

Second

aryou

tcom

es

4.Co-occurringmen

tal

illne

ss-AA,m

orning

,psychoe

ducatio

nal

grou

psIncreasedun

derstand

ingof

substancemisuse

(e.g.trig

gers)andpe

rson

alstrategies

(e.g.

motivations,g

oals,tim

eout)forredu

cing

misuse

4.Redu

cedpsycho

logical

distress

(IRIS*/K10*)

5.Crim

inaljustice

involvem

ent

-Inform

alcoun

selling

No.of

externalcoun

selling

sessions

provided

5.Redu

ctionin

recidivism

(Pre/postcrim

inaljusticedata)

6.Chron

icph

ysicalhe

alth

need

sLife

skills

-Develop

daily

routine

Reconn

ectin

gclientsto

cultu

reandcoun

try

No.of

vocatio

nal-related

coursescompleted

6.Im

proved

physicalhe

alth

(Pre/postIndige

nous

health

checkou

tcom

es)

7.Tobaccouse

-Po

sitiverole-m

odelling

Relearning

daily

routineandstructureto

maintainahe

althylifestyleafterdischarge

No.of

clientsachieving

individu

alised

lifeskillsgo

als

7.Redu

ctionin

smoking

(RBD

Scale*

/self-repo

rt*/

COlevels*)

8.Une

mployed

/lim

ited

education

-Rede

veloppe

rson

alrespon

sibility

8.Im

provem

entin

employmen

tanded

ucation(3mth

follow-updata)

-Vo

catio

nalcou

rses

Learning

andde

veloping

work-readyand

commun

icationskills

-Literary/commun

icationskills

Timeou

tfro

msubstances

-Im

proveph

ysicalwellbeing

(eg.

sleeproutine/nu

trition

)Iden

tifyanden

gage

inpo

sitivealternative

activities

tosubstanceuseto

learnho

wto

take

timeou

tfro

msubstancesubstances

No.of

clientsen

gaging

inregu

larexercise

/cultu

ral

activities

-Im

proveph

ysicalwellbeing

(eg.

sleeproutine/nu

trition

)No.of

clientsqu

ittingor

redu

cing

smoking

-Sm

okingcessation

-Referralsto

services

post-discharge

(eg.

ACCHOs)

Con

tinue

toaccess

treatm

entandcare

requ

ired

tomaintainim

proved

health

andwellbeing

post

discharge

No.of

clientsmaintaining

abstinen

ce/not

involved

incrim

epo

stdischarge

-Providealistof

supp

ortservices

inclient’scommun

ity(eg.

AA)

Develop

ingaftercareprog

ram

post

dischargefro

mtreatm

ent

-Ong

oing

phon

econtact

*Measuredat

admission

,mid,d

ischarge

and3m

thspo

stdischa

rgefrom

theOHprog

ram

Munro et al. Health and Justice (2017) 5:12 Page 7 of 12

Table

2Orana

Haven

OrganisationalP

rogram

Logic

a.Organisationalareas

ofne

eda

b.Treatm

ent

c.Mechanism

sof

change

d.Processmeasures

e.Outcomes

Coreorganisatio

nalcom

ponents

Flexibleactivities

1.Effectivecultu

rally

safe

service

delivery

Linkswith

services

andothe

rne

tworks

-Partne

rships

with

localservices

Ong

oing

strong

partne

rships

with

localservice

providers

andexternalne

tworks

Type

andno

.ofservices

orprog

ramsintegrated

into

OHservicede

livery

Improved

prim

aryand

second

aryclient

outcom

es(Table1)

-Networks

across

thefield

(eg.

NADA,Bila

Muu

ji)Regu

larCQIfeedb

ackto

inform

locald

ecisionmaking

No.of

netw

orkmeetin

gsattend

ed-CQIcyclesandcapacity

building

2.Supp

ortedandskilled

staff

Staffskills

-Staffmustbe

client-cen

tred

Client-cen

tred

staffcommitted

toim

provingclient

outcom

esNo.of

stafftraining

completed

Improved

client

intake/

dischargedata

-Regu

larstafftraining

Pathwaysto

increase

andup

skillAbo

riginalstaffat

OH

No.of

Abo

riginalstaff

employed

atOH

Improved

staffretention

-Regu

larclinicalandcultu

ral

supe

rvision

Staffaresupp

ortedby

OHvia

regu

larclinicalandcultu

ral

supe

rvisionandaccess

totraining

No.of

staffreceiving

cultu

ral/clinicalsupe

rvision

3.Strong

governance

and

sustainability

Governance,rulesandroutine

-Regu

larBo

ardmeetin

gsStrong

vision

andpu

rposeof

OHprog

ram

No.of

Boardmeetin

gsProg

ram

Accreditatio

n

No.of

staffmeetin

gs-Ann

ualreview

strategicintent

tomeeton

goingaccred

itatio

nstandards

Locald

ecisionmakingfro

man

empo

wered

Boardandcommun

ityCurrent

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Munro et al. Health and Justice (2017) 5:12 Page 8 of 12

Munro et al. Health and Justice (2017) 5:12 Page 9 of 12

must also be supported via clinical and cultural supportand access to training.

Governance, rules and routine A strong program visionand purpose, as well as a robust, empowered and objectivegovernance structure is required to ensure effective deliv-ery of OH’s service delivery to clients as well as adequateresources. Furthermore, program governance needs to besupported by fair and consistent rules and routine, inaddition to ongoing quality improvement and capacitybuilding via collaborative research partnerships.

Orana Haven treatment and organisational program logicsA program logic is a depiction of a program designed toclearly align the problem being addressed with what theprogram will do, and articulate what aspects of theclients and the program will be measured. Two programlogics have been developed as a mechanism to operatio-nalisation the core components that summarise OH’sprogram delivery (Fig. 2). Table 1 relates to the coretreatment activities within the OH program and Table 2relates to the key organisational activities required tomaintain effective service provision. Both tables articulatethe following:

a.) Client or organisational areas of need. Outlines theprimary and secondary client needs that OH aims totarget, or the organisational areas of need, as definedin OH’s Strategic Intent;

b.)Treatment. Operationalises and describes associatedflexible activities of the central treatmentcomponent, five core treatment components, andthree organisational components;

c.)Mechanisms of change. Articulates key mechanismsof change for clients/organisation;

d.)Process measures. Specifies key processes to quantifyclient/organisational change; and

e.)Outcomes. Specifies key outcomes to measure orquantify client or organisational change.

DiscussionTo our knowledge, the process and outcome of re-searchers working in partnership with a remote Indigen-ous residential rehabilitation service to define, standardiseand operationalise core treatment and organisational com-ponents has not been undertaken, or at the very least, hasnot been extensively published in the peer reviewed litera-ture (James et al., 2017, under review). The Healing Modelof Care proposed in this paper articulates that a successfuladmission to a remote Indigenous drug and alcohol resi-dential rehabilitation service is that as a client’s quality oflife and cultural connectedness increases, risky substanceuse decreases.

The value of cultureMeasuring changes in cultural connectedness and qual-ity of life in conjunction with risky substance use amongIndigenous Australians admitted to residential rehabili-tation is also consistent with Indigenous peoples’ con-ceptualisation of health and wellbeing, both in Australiaand internationally, which recognises that culture is akey determinant of Indigenous health and wellbeing(NIDAC, 2014; Brady, 1995; Chenhall & Senior, 2013).Strengthening or reconnecting with culture is thereforeessential to Indigenous peoples’ healing and recoveryfrom substance misuse as it provides an importantprotective function (NIDAC, 2014; Chenhall & Senior,2013; Taylor et al., 2010; McCormick, 2000; Brady, 1995;Torres Stone et al., 2006). This explicit focus on the cen-trality of culture in treatment is the primary factor thatdistinguishes Indigenous from non-Indigenous treatmentservices. It is not to argue that Indigenous people do notbenefit from non-Indigenous services, nor that non-Indigenous people do not benefit from Indigenousservices, only that outcomes for Indigenous clients inIndigenous services are likely to be optimised by embra-cing and operationalising the concept of culture in treat-ment. Having recognised the potential primacy of thisconcept it now does, of course, require empirical evalu-ation (James et al., 2017, under review; Chenhall & Senior,2013; Chenhall & Senior, 2012; Gone & Calf, 2011).

The value of standardising core componentsDefining Indigenous residential rehabilitation programsusing standardised core components with flexible activ-ities specific to each service, as articulated in this paper,provides one possible solution to the problem of theinconsistent delivery and diverging views on the appro-priateness and efficacy of treatment components. Theauthors note there are a number of models that couldbe used to guide the development of services inaddition to the logic model framework that the researchpartnership have utilised in current example, such asOutcomes Star (MacKeith, 2011). However the primarydifference of the current research in comparison toother models, is that the research partnership havebeen able to define the service delivery in concreteterms in a way that is both standardised (core compo-nents) and flexible (specific activities). As such, a keystrength of this approach is that the definition does notrequire programs to adhere to a prescribed approach,but provides a structure within which different Indigen-ous drug and alcohol residential rehabilitation servicescan categorise preferred treatment activities to theirservice. For instance, services located in remote areaswill have different activities to services in metropolitanor coastal settings. Furthermore, programs in othercommunities may have more than these core

Munro et al. Health and Justice (2017) 5:12 Page 10 of 12

components, but are defined as being comparable toOH if they have these same core components, irre-spective of the specific activities developed and deliv-ered to suit the unique circumstances in which they arebeing implemented.

The value of standardising outcome measuresGiven the reported inconsistency in outcomes measuresutilised across Indigenous drug and alcohol residentialrehabilitation services both in Australia and internation-ally (James et al. 2017, under review), the adoption ofthe program logic framework delineated in this papermay help standardise the outcome measures used indifferent services. The potential suite of outcome mea-sures would likely increase over time to include otherdomains such as homelessness, specific health issues,family restoration and community-level benefits of pro-grams (NADA, 2009). Where possible, outcome mea-sures validated for use with Indigenous peoples wereselected for the current Healing Model of Care. Theseincluded the Growth and Empowerment Measure(GEM; Haswell et al., 2010), the Alcohol Use DisordersIdentification Test (AUDIT; Calabria et al., 2014), theIndigenous Risk Impact Screen (IRIS; Schlesinger et al.,2007), the Risk Behaviour Diagnosis Scale (RBD; Gouldet al., 2014), and the 10-item Kessler Psychological Dis-tress Scale (K10; Bougie, Arim, Kohen & Findlay, 2016).We recognise other outcome measures, namely theWorld Health Organization Quality of Life – BREF (ab-breviated version; WHOQoL-BREF) is not currently vali-dated for use with Indigenous peoples, but given thathealth education and behaviour studies are tested forvalidity and reliability inconsistently (Berry et al., 2013)and there have been no measures designed and validatedfor use within Indigenous drug and alcohol residentialrehabilitation settings, the authors consider this a pivotalarea for future research (Stephens et al., 2013; Jameset al., 2017, under review).

The value of the CBPR approachThe CBPR approach adopted in this study was foundto create a dynamic community-researcher partner-ship that facilitated meaningful data collection and in-terpretation over the duration of the 3-year studyperiod. Partnerships between researchers, communitymembers, clients and services, such as the examplepresented in this paper, therefore have great potentialto improve methodological quality and communityparticipation when research skills and communityknowledge are integrated to co-design, implement andevaluate community development projects (Munroet al., 2017, under review; Taylor et al., 2010; NIDAC,2014; Snijder et al., 2015).

ImplicationsFirst, the Healing Model of Care articulated in this papercould be easily be scaled up and applied across otherIndigenous drug and alcohol residential rehabilitationservices using a similar CBPR framework. By adopting amore standardised approach, the logic model specificallyaligns each treatment component and outcome with themechanism of change for the client or organisation,which then allows for rigorous evaluation and ongoingquality improvement to ensure improved outcomes. Assuch, this model has the potential to rapidly develop alarger and more rigorous evidence-base to improveoutcomes for clients attending Indigenous residentialrehabilitation services, both within Australia and inter-nationally, including for Native American or Maoriservices. It could therefore be adapted and applied to arange of cultural or ethnic minority communities wherethere may be key components or flexible activities ofeffective treatment that are specific to their culture. Assuch, this provides one possible solution to how to pro-vide better care for the large and growing population ofIndigenous people with substance dependence transi-tioning from custody to community. Second, no evalua-tions published to date have undertaken an economicanalysis to weigh the benefits of the treatment approachagainst its costs (James et al., 2017, under review). Thismakes it difficult for governments and other agencies tojustify funding programs on the basis of a likely economicreturn for their investment. Therefore, this paper recom-mends an economic analysis of Indigenous drug and alco-hol residential rehabilitation services to methodologicallyguide future efficiency and resource equity considerationsfor services, researchers and funding bodies.

ConclusionThere is a clear lack of rigorous evidence in the Indigen-ous drug and alcohol residential rehabilitation field dueto a number of factors. The description of the CBPRprocess and the Healing Model of Care presented in thispaper provides a possible solution to this problem by de-fining programs using standardised core componentswith flexible activities specific to each service. CBPR wasfound to be integral to enable this research process andhas the potential to expand the reach of research acrossother Indigenous drug and alcohol residential rehabilita-tion programs. By adopting a more standardised approach,Indigenous drug and alcohol residential rehabilitationservices would rapidly develop a larger and more rigor-ous evidence-base that would likely improve the effect-iveness of care provided to all clients accessing theseservices both in Australia and internationally, but par-ticularly the growing population of Indigenous peoplewith substance dependence transitioning from custodyto community.

Munro et al. Health and Justice (2017) 5:12 Page 11 of 12

AbbreviationsACCHO: Aboriginal Community Controlled Health Organisation;AH&MRC: Aboriginal Health and Medical Research Committee;AUDIT: Alcohol Use Disorders Identification Test; CO: Carbon monoxide;CQI: Continuous Quality Improvement; GEM: Growth and EmpowermentMeasure; IPA: Interpretative Phenomenological Analysis; IRIS: Indigenous RiskImpact Screen; K10: 10-item Kessler Psychological Distress Scale;NADA: Network of Alcohol and other Drugs Agency; NDARC: National Drugand Alcohol Research Centre; NH&MRC: National Health and MedicalResearch; NIDAC: National Indigenous Drug and Alcohol Council;NSQHC: National Safety and Quality in Health Care; OH: Orana HavenAboriginal Residential Rehabilitation Service; OSR: Aboriginal and Torres StraitIslander Online Services Report; RBD Scale: Risk Behaviour Diagnosis Scale;WHOQoL-BREF: World Health Organization Quality of Life – BREF(abbreviated version)

AcknowledgementsThe authors would like to acknowledge the dedication and support of theOrana Haven Board and its staff and clients.

FundingFar West Medicare Local.

Availability of data and materialsNot applicable.

Authors’ contributionsFirst author, AM devised the study, carried out the CBPR steps, interpretedthe data and drafted the manuscript. AS devised the study, carried out theCBPR steps, assisted with data interpretation and drafting the manuscript. ACassisted with the data interpretation and edited the manuscript. All authorsread and approved the final manuscript.

Authors’ informationAll authors have approved this manuscript for submission and are aware ofall policies relating to the Health & Justice journal.

Competing interestsWe declare no conflicts of interest with regards to this publication.

Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.

Author details1National Drug and Alcohol Research Centre, University of New South Wales,Sydney, NSW 2052, Australia. 2University of Queensland, Brisbane, QLD 4072,Australia.

Received: 10 July 2017 Accepted: 29 October 2017

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