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RESEARCH Open Access

Use and uptake of web-based therapeuticinterventions amongst Indigenouspopulations in Australia, New Zealand, theUnited States of America and Canada: ascoping reviewRachel Reilly1,2* , Jacqueline Stephens1,3, Jasmine Micklem4, Catalin Tufanaru5, Stephen Harfield1, Ike Fisher6,Odette Pearson1 and James Ward1

Abstract

Background: Barriers to receiving optimal healthcare exist for Indigenous populations globally for a range ofreasons. To overcome such barriers and enable greater access to basic and specialist care, developments ininformation and communication technologies are being applied. The focus of this scoping review is on web-basedtherapeutic 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 Indigenouspeoples 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 NewZealand, that were published in English, in peer-reviewed literature, from 2006 to 2018 (inclusive), were consideredfor inclusion in the review. Studies were considered if more than 50% of participants were Indigenous, or if resultswere reported separately for Indigenous participants.

Sources of evidence: Following a four-step search strategy in consultation with a research librarian, 12 databaseswere searched with a view to finding both published and unpublished studies.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) typesof WBTI used, (2) community uptake of WBTI, (3) factors that impact on uptake and (4) conclusions andrecommendations for practice.

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* Correspondence: [email protected] Health Equity, South Australian Health and Medical ResearchInstitute, Adelaide, South Australia, Australia2College of Medicine and Public Health, Flinders University, Bedford Park,South Australia, AustraliaFull list of author information is available at the end of the article

Reilly et al. Systematic Reviews (2020) 9:123 https://doi.org/10.1186/s13643-020-01374-x

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Results: A total of 31 studies met the inclusion criteria. The WBTI used were interactive websites, screening andassessment tools, management and monitoring tools, gamified avatar-based psychological therapy and decisionsupport tools. Other sources reported the use of mobile apps, multimedia messaging or a mixture of interventiontools. Most sources reported moderate uptake and improved health outcomes for Indigenous people. Suggestionsto improve uptake included as follows: tailoring content and presentation formats to be culturally relevant andappropriate, customisable and easy to use.

Conclusions: Culturally appropriate, evidence-based WBTI have the potential to improve health, overcometreatment barriers and reduce inequalities for Indigenous communities. Access to WBTI, alongside appropriatetraining, allows health care workers to better support their Indigenous clients. Developing WBTI in partnership withIndigenous communities ensures that these interventions are accepted and promoted by the communities.

Keywords: e-mental health, Digital technology, Aboriginal and Torres Strait Islander, Therapeutic intervention,Mobile health, e-health, Mental health, Chronic disease, Infectious disease, Information Technology, App

BackgroundIndigenous populations in Australia, New Zealand, theUnited States of America (USA) and Canada carry agreater burden of ill-health than the general populationsin their respective countries [1]. In each of these coun-tries, Indigenous populations also experience barriers toreceiving optimal health care due to mistrust of thehealth system resulting from historic and current mis-treatment, language and cultural differences and livingin geographically remote locations [1]. Globally, develop-ments in health information and communication tech-nologies (ICT) have been applied to overcome suchbarriers and to enable greater access to basic and spe-cialist care [2].In recent years, technological advances have also led

to the development of therapeutic interventions deliv-ered electronically for a range of health conditions. Thefocus of this review is on web-based therapeutic inter-ventions (WBTI), which are self-guided or clinician-assisted programmes delivered via the internet that aimto provide guidance, support and treatment for healthproblems. The proliferation of mobile devices, includingsmart phones and electronic tablets, means that web-based programmes and mobile applications (“apps”) canbe accessed at low cost by a range of populations, in-cluding culturally and linguistically diverse, or otherpopulations who may be otherwise disengaged with thehealth 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 havehigh rates of social platform use, indicating high levels ofinternet connectivity [3]. The recent roll-out of the “Na-tional Broadband Network” (NBN) in non-urban areasand other advances in technology have resulted in therise of telecommunication access in remote areas, whereinternet access was previously limited [4]. In recentyears, the increase in use of social platforms has been

significantly greater amongst Aboriginal and TorresStrait Islanders compared with that for all Australians,and a high level of engagement with social platforms hasbeen evident in the health sector [5–7]. Together, ad-vancements and high level use of ICT by IndigenousAustralians across all areas of remoteness and sociode-mographic spectrum clearly indicate a potential to en-gage 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 deter-minants of health and wellbeing [5], given the feasibilityof capturing personalised health-related social and be-havioural information that was not previously accessible,with direct implications to people living with chronicdiseases. Worldwide, there are over 250,000 differentconsumer-targeted mobile health apps, though few havebeen rigorously evaluated regarding the accuracy of infor-mation they provide, privacy and digital security protec-tions, and their usability, functionality and effectiveness inthe context of health [8]. As the use of online therapiescontinues to grow, this review of international evidenceon WBTI for health conditions amongst Indigenous popu-lations is timely.A previous scoping study has examined the evidence

for the effectiveness of web-based and mobile technolo-gies in health promotion, specifically to reach Indigen-ous Australians [9]. This valuable piece of work focusedon social media and mobile apps primarily for smokingcessation, many of which did not appear in the peer-reviewed literature. The current review provides an up-date on the peer-reviewed evidence of the acceptability,validity and effectiveness of WBTI for a broad range ofhealth conditions, extending the review to include WBTIdeveloped with Indigenous people internationally forcommunicable and non-communicable diseases, mentalhealth conditions (including the broader concept of so-cial and emotional wellbeing), or issues relating to the

Reilly et al. Systematic Reviews (2020) 9:123 of 17

use of harmful substances, and problem gambling. Theobjective of this scoping review is to identify and de-scribe the available international scientific evidence onWBTI used by Indigenous peoples in Australia, NewZealand, Canada and USA for managing and treatinghealth conditions. These four countries were includeddue to similar persistent patterns of inequities that havearisen in these countries since colonisation, as well asgeographic and demographic similarities such as remote-ness from health services and differing language, cultureand concepts of health and illness from the dominantculture [1]. Additionally, these four countries have othercommonalities which allow for comparison; they are de-veloped, democratic, wealthy countries with similarstandard of living and life expectancy [10].

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

Information sourcesA systematic search was conducted of the following da-tabases: PubMed, CINAHL, Embase, ATSIHealth viaInformit online, Web of Science, APAIS Health data-bases, Australian Indigenous Health InfoNet and the Pri-mary Health Care Research Information Service(PHCRIS). A search for unpublished studies was con-ducted by accessing Mednar, Trove, Google, OCLCWorldCatDissertations and Theses, and Proquest Disser-tations and Theses. The search in Trove was limited totheses only, as the assumption was made that other

publication types would be captured in the other data-bases. To capture additional literature, a search of web-sites and clearing houses that provided information,links and resources relating to Indigenous health in eachof the four countries that are the focus of this reviewwas conducted using initial keywords including the fol-lowing: Indigenous, Aboriginal, Torres Strait Islander,Maori, First Nations, First Peoples, Metis, Inuit, NativeAmerican, eHealth, telehealth, internet-based interven-tion and web-based therapeutic tool.

Search strategyAs outlined in the scoping review protocol [11], a four-step search strategy was followed in consultation with aresearch librarian, with a view to finding both publishedand unpublished studies. An initial limited search ofPubMed was undertaken. The final search strategy forPubMed can be found in Table 1. An analysis of the textwords contained in the titles and abstracts, and of theindex terms used to describe articles then informed thedevelopment of search strategies tailored for each infor-mation source. A second search using all identified key-words and index terms was undertaken across all otherinformation sources. The reference list of all studies se-lected for inclusion was screened for additional studies.The search strategy allowed for authors to be contactedand experts consulted with a view to accessing any un-published data or for clarification of published informa-tion; however, this was not necessary in practice. Thesearch was conducted on 10 April, 2019.

Inclusion criteriaDate rangeStudies published from 2006 to 2018 (inclusive) in Eng-lish were considered for inclusion. This timeframe was

Table 1 Search Strategy for PubMed

Category Search terms

Population ofinterest

((“Oceanic Ancestry Group”[mh] OR Aborig*[tw] OR Indigen*[tw] OR (Torres Strait[tw] AND Islander*[tw]) OR “health services,indigenous”[mh]) AND (.au[ad] OR australia[ad] OR Australia[mh] OR Australia[tiab] OR Northern Territory[tiab] OR NorthernTerritory[ad] OR Tasmania[tiab] OR Tasmania[ad] OR New South Wales[tiab] OR New South Wales[ad] OR Victoria[tiab] ORVictoria[ad] OR Queensland[tiab] OR Queensland[ad])) OR Native American[tiab] OR Maori*[tiab] OR (indigenous[tiab] AND newzealand[tiab]) OR “Indians, North American”[mh] OR “Inuits”[mh] OR Inuit*[tiab] OR first nation*[tiab] OR “Alaska Natives”[mh] ORmetis[tiab] OR Eskimo*[tiab] OR Canada[mh] OR United States[mh]

Intervention “telemedicine”[mh] OR telemed*[tiab] OR ehealth[tiab] OR e-health[tiab] OR web*[tiab] OR internet[tiab] OR computer*[tiab] ORmobile[tiab] OR app*[tiab] OR apps[tiab] OR blog*[tiab] OR “social media”[tiab] OR iphone*[tiab] OR smartphone*[tiab] OR “smartphone*”[tiab]

Health issues (“mental disorders”[mh] OR “gambling”[mh] OR “chronic disease”[mh] OR “exercise”[mh] OR “delivery of health care”[mh] OR “selfcare”[mh] OR “disease management”[mh] OR “nutrition therapy”[mh] OR “health behavior”[mh] OR “psychotherapy”[mh] OR“patient acceptance of health care”[mh] OR depress*[tiab] OR anxiety[tiab] OR suicid*[tiab] OR “stress management[tiab] ORaddict*[tiab] OR drug*[tiab] OR methamphetamine*[tiab] OR alcohol*[tiab] OR ice[tiab] OR meth[tiab] OR amphetamine*[tiab] ORheroin[tiab] OR inhalant*[tiab] OR marijuana[tiab] OR cannabis[tiab] OR morphine[tiab] OR buprenorphine[tiab] ORmethadone[tiab] OR speed[tiab] OR crystal[tiab] OR LSD[tiab] OR ecstasy[tiab] OR cocaine[tiab] OR GHB[tiab] OR MDMA[tiab] ORketamine[tiab] OR solvent*[tiab] OR opioid*[tiab] OR opiate*[tiab] OR narcotic*[tiab] OR illicit[tiab] OR binge drink*[tiab] ORtobacco[tiab] OR smok*[tiab] OR wellbeing[tiab] OR well being[tiab] OR nutrition[tiab] OR diet[tiab] OR medication[tiab] ORadherence[tiab] OR complian*[tiab] OR self manag*[tiab] OR pain manag*[tiab])


considered sufficient to capture up-to-date evidence onWBTI that have grown in popularity in recent years.

Publication statusPeer-reviewed and grey literature meeting the inclusioncriteria were considered for inclusion.

ParticipantsStudies assessing WBTI designed for Indigenous peoplesof any age in Australia, Canada, USA and New Zealandwere considered for inclusion in the review. Participantscould be accessing the WBTI to prevent, manage ortreat their own health condition; or could be healthcareproviders, friends or family members accessing a WBTIto assist an Indigenous person with a health condition.Studies were considered if more than 50% of participantswere Indigenous, or if results were reported separatelyfor the Indigenous participants.

ConceptThe focus of this review was on the use and uptake ofWBTI by Indigenous people. The range of possiblehealth issues the WBTI could address was deliberatelybroad and included chronic physical illness, communic-able disease, mental health conditions and issues relatingto social and emotional wellbeing, use of harmful sub-stances or gambling. Studies were considered for inclu-sion if they provided information on WBTI used byindividuals or groups: either autonomously or with as-sistance, to assess, manage or treat health conditions by(a) modifying lifestyle behaviours, (b) promoting socialand emotional wellbeing and resilience, (c) supportingadherence to treatment regimens, (d) increasing motiv-ation to reduce risky behaviours and (e) providing andsupporting strategies to reduce dependence on alcohol,prescription drugs, illicit substances or gambling. Evalua-tions of websites that only provide health educationwithout any interactive or therapeutic content were ex-cluded. This included interventions involving health in-formation kiosks or telehealth as the sole interventionstrategy.

ContextHealth-related WBTI accessed in any setting inAustralia, New Zealand, Canada and USA wereincluded.

Selection of sourcesFollowing the search, all identified citations wereuploaded into EndnoteTM (Version X8.1, Clarivate Ana-lytics, Philadelphia, USA) and duplicates removed. Cita-tions were then entered into an online systematic reviewmanagement system (www.covidence.org, 2019, VeritasHealth Innovation Ltd, Melbourne, Australia). Titles and

abstracts were screened against the inclusion criteria byone researcher (RR), as well as independently by one oftwo other researchers (SH, IF). Disagreements were re-solved through discussion between all three reviewers.Studies that potentially met the inclusion criteria wereretrieved in full and imported into Covidence for fulltext review. The full texts of selected studies wereassessed in detail against the inclusion criteria by at leasttwo reviewers (RR, and either SH, FS or IF). Full textstudies that did not meet the inclusion criteria were ex-cluded and reasons for exclusion recorded.

Data charting and synthesisTwo data extraction tools were developed for this scop-ing review [11], which were further refined during thedata charting process. This tool facilitated the extractionof the data mapped to the variables outlined in Table 2.Extracted data was synthesised and reported under fourmain conceptual categories: (1) types of WBTI used, (2)community uptake of WBTI, (3) factors that impact onuptake and (4) conclusions and recommendations forpractice.

ResultsSources of evidenceThe systematic searches identified 8182 references andone additional reference was identified through othersources (Fig. 1). After duplicates were removed, therewere 1618 unique papers for review. The large numberof duplicates stems from many studies being duplicatedacross multiple databases. Title and abstract screeningexcluded 1420 references, and a further 166 papers wereexcluded on full-text review, resulting in 31 studiesmeeting the inclusion criteria for this scoping review.

Characteristics of sourcesAs shown in Table 3, 11 (34%) sources were from theUSA [15–25] and nine (28%) sources were from NewZealand [26–34], with the remainder from Australia (12,38%) [35–45]. As there were no studies from Canada,the findings reported from here on pertain to NewZealand, the USA and Australia. The majority reportedevaluation studies (52%) [16–18, 22, 23, 25, 29, 31, 32,34–36, 38, 39, 43, 45] and had prospective (94%) datacollection [15–28, 30–33, 35–43, 45]. There was an in-creasing number of publications over time. As shown inTable 4, health topics addressed in the reported studies werevaried; however, mental health (32%) [24, 27, 31, 32, 36, 37,39, 41–43] and substance use (19%) [16, 18, 21, 22, 28] werethe two prominent issues targeted. Most sources reportedstudies that focused on interventions with consumers (82%),although four (18%) [24, 34, 36, 37, 39, 43] sources reportedthe use of WBTI to support healthcare workers. There were


http://www.covidence.org

Table 2 Data extraction variables

Variable name Description

Author The surname of the first author of the source publication.

Year Year study published.

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)

Healthcondition

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.

Fig. 1 PRISMA flow diagram of the complete search process


no clear patterns of similarity or differences between coun-tries in any of the variables reported.

Types of WBTI usedThe types of WBTI described in the source publications arepresented in Tables 4 and 5. The majority of the interven-tions used in these studies were interactive websites (n = 21,of 25 interventions in the 32 studies, 84%), providing educa-tion modules and tutorials [15, 16, 19, 22, 25–27, 29, 36],screening and assessment tools [18, 21], management andmonitoring tools [20, 23, 28, 34, 38], gamified avatar-basedcognitive behaviour therapy (CBT) [31, 32] and decision sup-port tools [24, 30]. Seven sources reported the use of mobile“apps” [17, 33, 39, 41–43, 45], two sources incorporated theuse of text or multimedia messaging service [35, 40] and two

sources studied an intervention that used a mixture of inter-vention tools [37, 44].Most interventions were self-directed (n = 19, 61.3%), re-

quiring the user to access the WBTI program, often ac-cording to a pre-defined schedule, without support from anoutside agency or healthcare worker [16, 18, 19, 21–26, 29–34, 37, 38, 41, 42, 45]. The remainder of the interventionswere either supported by a healthcare worker or otherpersonnel [17, 20, 27, 28, 35, 36, 39, 43, 44], were supportedinitially but then relied on users to be self-directed there-after [15] or were passive [40], such as the receipt of inter-mittent text messages that contained health messages orgraphics intended to prompt a behavioural response.

Uptake and effects of WBTIThe bulk of the sources reported improved health outcomesfor Indigenous people [15, 16, 18–20, 22, 24, 28, 31, 33–38, 41].For the three studies that reported uptake, voluntary uptake ofWBTI was between 30 and 56% [15, 27, 36, 37]. The remainderof the sources had the WBTI as a prescribed component of thereported intervention or evaluation study so rate of uptake isnot relevant; however, contextual factors identified by study au-thors as influences on uptake, use and acceptability are dis-cussed below.None of the WBTI approaches had a negative impact

on participants. However, some WBTI were more suc-cessful than others. Two randomised clinical trials re-ported statistically significant differences in quantitativemeasures of depression amongst Indigenous adolescents(USA and NZ) who used WBTI “apps” compared tothose who did not [27, 42], while a qualitative studyfound substantial improvements in mood amongstMaori adolescents who used a gamified app [32]. Aninterventional study using WBTI with Native Americansfor diabetes control showed a statistically significant im-provement in glycated haemoglobin levels [23], and aneducational tool for preventing sudden infant death inNew Zealand significantly increased the confidence ofMaori people to discuss infant sleep safety with otherscompared with non-Indigenous people [26].Two sources reported no impact of the intervention. In the

USA, risky drinking behaviour by women living in Californiadecreased regardless of whether they received the WBTI or“usual care” [21]. In Australia, while health messages sent viatext message did not impact on clinic attendance for childrenwith otitis media [40], the content delivered in local Indigen-ous languages was found to be culturally appropriate and re-cipients were happy to receive the information.

Explanations for uptakeWhile some sources provided no explicit explanations foruptake success or failure [18, 30, 35], most did. Sourcessuggested a variety of factors that could improve WBTIuptake; however, the most important was ensuring that

Table 3 General characteristics of included publications

Characteristic Number Percentage (%)

Country

New Zealand 9 29 %

Australia 11 36 %

USA 11 36 %

Publication year

2006–2009 4 13%

2010–2014 10 32%

2015–2018 17 55%

Study type

Case study 1 3%

Evaluation study 16 52%

Feasibility trial 4 13%

Observational study 3 10%

Qualitative study 2 6%

Randomised trial 5 16%

Study design

Prospective 29 94%

Retrospective 2 6%

Topic

Cardiac care 3 10%

Diabetes 3 10%

General/nutrition 4 13%

Mental health 11 36%

Other (asthma, neonatal, otitis media) 3 10%

Smoking cessation 2 6%

Substance misuse 5 16%

Population

Consumers 27 87%

Healthcare workers 4 13%

Adolescents 8 25%


WBTI were designed for the audience [23, 44], culturallyrelevant and appropriate [40, 41, 43], by having culturallyrelevant graphics, voices and animations [40], and showingtraditional practices, culture and Indigenous peoples [16, 44].It was also important that content was matched to partici-pants’ values and experiences. For example, Campbell et al.[16] reported that ratings of some modules varied accordingto experiences of discrimination or mainstream comfort.Cultural appropriateness of the WBTI was explicitly discussedand/or evaluated in all but four sources [26, 30, 34, 35].Where authors discussed cultural appropriateness, it waslinked to better outcomes in terms of acceptability, uptakeand impact, whether or not this was formally evaluated.Seven sources reported recommendations from theirstudy populations on features to improve so as to ensurethe WBTI contain a greater volume of culturally appropri-ate 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 thought-provoking [24]. These interventions fostered conversa-tions [24] and resulted in improved patient-practitionerrelationship which led to better health monitoring by pa-tients [20, 29]. However, one source reported that videossent via multimedia messaging services may be unclearor confusing and suggested that simple text messagesmay be more effective [40]. Users like the flexible deliv-ery that WBTI allow [23, 38] and want WBTI to be easyto use [41, 43] and customisable [38]. However, usersalso preferred to be able to download the “app” or soft-ware for free [41]. Limited access to internet or a phonewere found to be prohibitive factors by users [15, 41],with mental health workers reporting significant organ-isational and personal barriers to accessing mentalhealth web-based apps [36]. Systemic or policy contextsthat influenced uptake and use included the following:organisational support for the WBTI [36], access to theinternet or other technology due to cost or the

Table 4 Multi-way cross-classification matrix: health focus, delivery mode and intervention by country

Health focus Delivery mode Intervention No. of studies

Aust NZ USA

Mental health Service provider R U Appy (Bennet-Levy) 1

DM-DS(Starks) 1

Self-administered Sparx (Fleming; Shepherd(2)) 3

iBobbly (Povey*; Tighe) 1.5

Administered with HCP support Stay Strong (Dingwall (2); Povey*; Bird) 3.5

Stayin on Track (Fletcher) 1

Harmful alcohol and illicit drug use Self-administered Therapeutic education system (Campbell) 1

SBIRT (Gorman; Montag) 2

e-SBINZ (Kypri) 1

Hawk 2 (Raghupath) 1

Smoking cessation Self-administered SmokingZine (Bowan; Taualii) 2

Cardiac Service Provider PREDICT-CVD (Riddell; Whittaker) 2

Administered with HCP support CSIRO Cardiac rehab (Bradford) 1

Diabetes Self-administered Kaya Tracker (Robertson) 1

Administered with HCP support Stanford IDSMW (Johnson) 1

My Care Team (Levine) 1

General health/ nutrition Self-administered Gigiigoo’inaan (Dellinger) 1

SSB (Tonkin) 1

Wellness mHealth Program (Verbiest) 1

Administered with HCP support Diet Bytes (Ashman) 1

Other:• Asthma• Sudden Infant Death• Otitis Media

Service provider GASP (Ram) 1

Self-administered Baby Essentials online (Cowan) 1

Non-interactive Otitis Media MMS (Phillips) 1

Total health foci: 9 Total programmes for service providers: 4Self-administered: 12Non-interactive: 1Administered with assistance: 6

Total individual programmes: 23 *Povey includes twoprogrammes.


Table 5 Summary of research findings from included publicationsFirst author (year)CountryFunding

Study population andcontext

Aim/method andhealth condition

Intervention anddelivery type

Measured impacts/outcomes (results)

Explanations providedfor uptake and effects

Authors’ conclusions/recommendations

Ashman (2016)[35]AustraliaFunding: NHMRCUniversity ofNewcastle

27 women, 8Indigenous (aged >17,gestation <25 weeks),median age 28. 8regional outpatientsettings (hospital, GPclinics, communityorganisations), NewSouth Wales (NSW)

Aim: To usesmartphones to takedetailed assessmentsof dietary intake, andprovide personalisedonline feedback, withdietician consultation.Method: Quantitativeevaluation study. Thewomen collectedimage-based dietaryrecords, completed 24-h food recalls and afood frequency ques-tionnaire, as well as 3online surveys.

12-week study of “DietBytes” and “SNaQ”methods. Smartphonesused to record dietaryintake and participantsreceived a video withpersonalised advicecomparing their intaketo the AustralianGuidelines, thenphone contact with anutritionist.

N = 17, 77% reporteddietary changes as aresult of feedback.Core food groupconsumption wasreported separately forIndigenous women.Intake was close torecommendations forfruit and dairy butbelow for grains,cereals, vegetables andmeat. All Indigenouswomen metrecommendations forunsaturated spreadsand oils.

Based on thepersonalised feedback,some ate more foodsfrom core foodgroups, othersconsumed less sugarydrinks or “junk” foods.Others changedcooking methodsLess than half theparticipants felt theyhad enoughinformation abouthealthy eating at thetime of enrolment.

The Diet Bytes methodfor nutritionassessment combinedwith the SNaQ tool foranalysing nutritionalcontent, with theprovision of personallytailored feedback, maybe a useful method fordietitians to assistwomen in optimisingtheir food and nutrientintakes duringpregnancy.

Bennett-Levy(2017) [36]AustraliaFunding:Australian FederalGovernment

26 health professionals(21 Indigenous) inregional centres innorthern NSW.

Aim: To identify thebarriers and enablersof e-mental health (e-MH) uptake amongstmainly Aboriginal andTorres Strait Islanderhealth professionals.Method: Qualitativeevaluation study.Trainers providedwritten reports andwere interviewed.These data sourceswere analysedthematically.

A 3- or 2-day e-MHtraining programmeentitled: “R U Appy”was followed by up to5 consultation sessions(mean 2.4 sessions).Training focused ondownload and use ofapps, with a focus onthe app “Stay Strong”on one of the days.

Uptake of e-MH in theconsultation groupwas moderate (22–30% of participants).Barriers to uptake weregrouped into two cat-egories: “Organisa-tional” and “Participantperceptions”. Enablerswere also groupedinto two categories:“Organisational” and“Positive experience ofthe consultationssessions.

Features of theorganisation acted asboth barriers andfacilitators to uptake.Where senior staffwere supportive,uptake was greater. Agood match betweenresources and workrole led to excitementamongst participantsabout the possibility ofusing YouTube clipsand apps for healtheducation.

Researchers shouldbroaden their focusand definitions of e-MH, emphasising theeducational potentialof resources, as well astherapeutic potential.Developing criteria forevaluating apps maypromote uptake.

Bird (2017) [37]AustraliaFunding:Australian FederalGovernment

16 Aboriginal serviceproviders in the healthand community-service sectors in re-gional/rural areas ofnorthern NSW.

Aim: 4–8-monthfollow-up on use of e-MH resources follow-ing an e-MH trainingprogramme and to de-termine what types ofe-MH resources theyused.Method: Qualitativeevaluation study. 16semi-structured inter-views were transcribedand thematicallyanalysed.

This study was a 4–8-month follow-up of “RU Appy” training,which involved a 3- or2-day e-MH trainingprogramme then upto 6 monthly skills-based consultationsessions deliveredface-to-face.

9 of the 16 serviceproviders were usinge-MH in their practicefor a variety of pur-poses, including sup-porting socialinclusion, self-care,education, referral, as-sessment, crisis re-sponse, and casemanagement. Usetended not to includetreatment of depres-sion/anxiety.

Participants preferrede-MH resources thatwere easily accessedvia mobile devices. Re-sources for treatinganxiety/depressionwere not preferred,perhaps due to theprofessional back-grounds of partici-pants, or becausemental health con-cepts were not cultur-ally relevant.

Workforces havecharacteristics thataffect the uptake anduse of e-MH resources.There is a need to fos-ter production of cul-turally relevantresources to supportSEWB and treat mentalhealth disorders

Bowen (2012) [15]United States ofAmerica (USA)Funding:National CancerInstitute

113 American Indian(AI) youth (12-18 years)recruited during a 6-week residential sum-mer camp for Ameri-can Indian students(6th to 12th grade) inRapid City, SouthDakota.

Aim: To evaluate asmoking preventionand cessationinterventionMethod: Randomisedcontrol feasibility trialwith 1-month follow-up. After baseline as-sessment, studentswere randomised tohave regular access tothe site or not. All par-ticipants completed afollow-up assessment1-month postrandomisation.

Self-directededucationalprogramme(“SmokingZine”).Participants wereencouraged to accessit as often as they likeover six weeks andhad daily 1-h com-puter time. Modulescovered education, be-haviour change goals,positive values andidentifying barriers tochange.

52% uptake inintervention arm. Theintervention did notdirectly affect smokingbehaviour but did alterintentions to usetobacco amongstnever-smokers.

Small sample, lack ofstatistical power.Selection bias- highgrade point averageand low rate ofsmoking at baseline.Limited access to theWeb at the camp mayhave reducedengagement. A “groupdesign” for futureprogrammes whereyouth can use the sitetogether.

Partial support for thepotential of the toolfor future research,and support for thefeasibility of futureresearch on smokingcessation programmesdesigned for AmericanIndians and AlaskaNatives.

Bradford (2015)[38]AustraliaFunding:CommonwealthScientific andIndustrial ResearchOrganisation(CSIRO)

Non-indigenousresearchers from theCSIRO consulted: staffof 1 remote Aboriginalhealth service; 1 urbanIndigenous healthinstitute; and cardiac/Indigenous healthspecialists.

Aim: To adapt anestablished mobilephone deliveredcardiac rehabilitationprogramme forIndigenous people.Method: Consultationwith stakeholders andemployment ofIndigenous production

Smartphone app todelivered over 6 weeksto provide cardiacrehab in the patient’shome in line with theirlifestyle. Includesclinical portal,mentoring andeducational material.

Modifications includedflexibility in theduration of delivery,inclusion of positivemeasures, use ofmentors, a meetingplace for using theapp and takingphysical measures,changes to

Smartphoneprogramme not yettested but based onprevious research withmainstreampopulations, theauthors anticipatepositive results. Theadapted smartphoneapp is ready for further

Mobile deliverysignificantly improvesprimary outcomesover traditional cardiacrehabilitation care andif replicated inIndigenouspopulations, theprogramme has thepotential to


Table 5 Summary of research findings from included publications (Continued)First author (year)CountryFunding







company. Paperoutlines the changesmade followingconsultation.

educational contentwords, look and feel.

communityconsultation and trial.

significantly improvelife expectancy

Campbell (2015)[16]USAFunding:National DrugAbuse TreatmentClinical TrialsNetwork; NationalInstitute on DrugAbuse (NIDA)

N = 40 AI/ AlaskaNative (AN), mean age37.5; 47.5% women,recruited via twourban outpatient drugtreatmentprogrammes, NorthernPlains and PacificNorth-west regions.

Aim: To testacceptability of a web-based version of atherapeutic educationsystem (TES) for drugtreatment.Method: Participantscompleted baselineassessments then 1week after theintervention phase,follow-up assessmentsplus qualitativeinterview.

Self-directed andcomprised 32interactive, multimediamodules based on theCommunityReinforcementApproach (CRA).Delivered over 8weeks on computersin the treatmentsettings.

TES was acceptableacross sevenquantitative indices.Qualitative findingsindicated (1) contentwas relevant and (2)acceptability would beenhanced by betterAI/AN representationacross several contentdomains, and removalof content that iscounter to AI/ANculture.

Acceptability ofmodules variedaccording to personalcharacteristics orexperiences ofparticipants, includingperceiveddiscrimination and“ethnic experience”.Participants ratedthose modules withSTI/HIV informationmost highly.

Evidence-based,culturally informed,web interventions mayaddress barriers totreatment in AI/ANcommunities.Adaptations can bemade without losingfidelity. Researchshould incorporatecultural acceptabilityand a wider range ofimplementation issues.

Cowan (2013) [26]New Zealand (NZ)Funding: NZMinistry of Health

N = 2683 completed“sessions” of use ofinternet link andconfidence rating in. N= 207 Maori peoplecompleted theprogram.

Aim: to describe use,impact and reach ofan online educationtool for preventingsudden infant death.Method: online toolpromoted widely, andbasic usage datacollected online.

Baby Essentials Onlinewas a self-directededucation, 1~15-minsession of 24 slides,followed by assess-ment of “increasedconfidence” (IC)

Of Maori participants,53 rated their IC as“low” and 154 ratedtheir IC as “high.”

The greater IC in Maoriwith no greater timeper slide may reflectlower startingknowledge andconfidence

Help reducing SUDI inthe Maori population,the online toolextended educationopportunities beyondthe traditional face-to-face delivery modeand is cost-effective

Dellinger (2018)[17]USAFunding: NationalInstitute forEnvironmentalHealth Sciences;Sault Ste. MarieTribe of ChippewaIndians

N = 24 (13 women)Anishinaabe (NativeAmerican), aged 25-55+, Great Lakesregion.

Aim: To describe thedevelopment andacceptability of an app“Gigiigoo’inaan”, whichaims to improvenutrition viapersonalised, culturallytailored advice on fishcontaminants.Method: Mixedmethods-qualitativeand quantitative (sur-vey) feedback ob-tained during focusgroups.

Gigiigoo’inaan [OurFish] is an appdelivered on mobilephone and/or internetthat providespersonalised risk andbenefit information onfish species based onuser input information.

61% said they wouldconsume more fish ifthey had regularaccess to the app; 75%agreed the app wasuseful, culturallyappropriate andhelped them identifyfish to eat.However, somereported confusionabout encouragementto eat fish combinedwith warnings recontaminant levels.

Negative emotionsrelating to appcompounded by: (1)historical distrust; (2)the potential foremotional harm(disproportionate tothe actual risk) fromlearning of aboveaverage exposure; (3)concerns that the datamay misused tostigmatise Anishinaabeculture, and (4) anattitude of communalprivacy.

Testing of the pilotsoftware demonstratesthe value of designingculturally adapted riskcommunication withvulnerablepopulations. The appmay help to regaincommunity interestand faith in naturalresources. The findingssupport theassumption that thecommunity seeks topromote thestewardship of naturalresources.

Dingwall (2015a)[39]AustraliaFunding:Australian FederalGovernment

N = 138 (70% women,35% Indigenous), aged19-74 (M = 40.41, SD12.86) service pro-viders working with In-digenous people inthe Northern Territory

Aim: To evaluateawareness, knowledgeand confidence in e-mental health and theAIMhi Stay Strong AppMethod: Pre-postquestionnaires on con-fidence and use of e-mental health toolswith Indigenousclients.

Face-to-face trainingprogramme “Yarningabout Indigenousmental health usingthe AIMhi Stay StrongApp”. Duration notprovided.

Significantimprovements acrossall measures of skilland knowledge exceptfor confidence in usingcomputers

Limited awareness ofe-mental health toolsprior to training. Theincrease in confidenceand knowledge post-training is promisingbut it is not knownwhether this will trans-late into use.

E-mental health toolshave potential toimprove access toculturally appropriatemental health care forIndigenous Peopleswith minimal trainingbut more researchrequired into uptakeand use.

Dingwall (2015b)[43]AustraliaFunding:Australian FederalGovernment

15 service providersfrom rural and remotehealth servicesworking withIndigenous people inthe Northern Territory,

Aim: To assessacceptability, feasibility,and appropriateness ofa new e-MH resourcefor service providers.Method: semi-structured interviewsabout barriers, en-ablers, acceptabilityand feasibility of use

Clinician-assisted,Interactive app (AIMhiStay Strong). A briefintervention focusingon worries andstrengths, andenabling personal andbehavioural goal-setting

Positive feedback onall aspects of the app.Thematic analysisrevealed support forthe acceptability,feasibility, andappropriateness of theresource amongstservice providers

Simple language andvisual appeal wereidentified as strengths.Participants indicatedthat the app would beparticularly useful forclient engagement,and that it enabled aclient-centred ap-proach. Barriers to useinclude access topower and internet.

e-MH interventions arelikely to make animportant contributionto overcoming theburden of poor serviceaccess for remoteIndigenous clientsincluding new deliveryways for health inremote regions

Fleming (2012)[27]NZFunding: NZ

N = 32 adolescentsaged 13-16: 34%Maori; 38% Pacifica;56% male completed

Aim: To investigatethe efficacy of theSPARX programme forsymptoms of

SPARX comprises 7 30-min self-administeredmodules. 1–2 com-pleted / week. CBT-

Reductions indepression frombaseline to week 5compared to control,

Good completion ratesattributed to graphicinterface specificallydesigned for young

Delivery online and inschool helpedovercomeembarrassment- a









Ministry of Health;NZ TertiaryEducationCommission

SPARX during schoolclass time.

depressionMethod: Randomisedwait-list control trial.Immediate vs delayedtreatment (5 weeks).10-week follow-up

based content includ-ing relaxation, problemsolving, activity sched-uling, challengingnegative thinking andsocial skills.

changes sustained 10-week follow-up. Nosignificant changes inanxiety, locus on con-trol or quality of life.

people and deliveryduring class time.Good uptake occurredwhere the programmewas opt-out (i.e. deliv-ered as part of schoolcurriculum) rather thanvolunteer.

known barrier to help-seeking. SPARX haspromise as an inter-vention for youngpeople who may bereluctant to engage intraditional healthservices.

Fletcher (2017)[44]AustraliaFunding: Youngand wellCooperativeResearch Centre;University ofNewcastle

N = 20 Aboriginalfathers aged 18-25 re-cruited throughACCHS and commu-nity networks in urban,regional and rurallocations.

Aim: To test theacceptability andfeasibility a websitewith tailored supportto young fathers andto adapt and test amobile phone-basedtext message andmood-tracker program.Methods: Participatoryqualitative methodsincluding: “yarn-up”discussions, filmingfathers’ stories, andSMS messaging.Participants andcommunity gavefeedback on allaspects.

Stayin on Track is awebsite withinformation, films andSMS messaging foryoung fathers. SMSwas used to monitormood and sendencouragingmessages. Participantswere supported bysenior mentors. Thewebsite was promotedvia communitynetworks and ACCHSstaff.

Links sent by SMS onparent routines and“baby talk”.Information on crying,post-natal depressionand bonding for dadswere not highlyaccessed. Most partici-pants reported positivemood (91.5%). Com-munity feedback waspositive.

Key to the success ofthe programme wasthe close researchpartnership with thecommunities involved,and the involvementof the fathers indeveloping thewebsite content, andthe involvement ofmentors. Onlinedelivery can help toovercome barriers toaccess to culturallyappropriate resources.

Providing tailoredonline resources toAboriginal fathers isfeasible andacceptable. Throughtheir involvement inthe project, the youngfathers saw themselvesas mentors who couldsupport other youngmen, thus enhancingproject sustainability.Authors recommendrefining the mentoringmodel and conductingfurther evaluation.

Gorman (2013)[18]USAFunding: sourcenot provided

N = 21: 15 AI/ANwomen of child-bearing age represent-ing 9 tribes, and 6 keyinformants inCalifornia.

Aim: To modify andevaluate a mainstreamweb-based behav-ioural intervention(SBIRT) on prenatal al-cohol use for AI/ANwomen.Method: semi-structured focusgroups and interviews.Data were transcribed;cross-case inductiveanalysis was used toidentify themes.

Self-administered Web-based programme forscreening and preven-tion of prenatal alco-hol use, with orwithout personalisedfeedback.

5 themes: Make theprogramme relatable;stress confidentiality;incorporate family/community focus;tailor content tocommunity; andinclude information onhealth effects forchildren.

Effectiveness notknown. Participatorydevelopmentprocesses wereessential for buildingrelationships and trustin context where thereis low trust of research.

This programme hasthe potential toprovide a culturallyappropriate, cost-effective approach toassess and preventprenatal alcohol use.

Jernigan (2011)USA [19]Funding: sourcenot provided

N = 54: 27 NativeAmerican (AI/AN)representing 18 tribesin urban andreservation settings,and 27 non-Native)participants. All haddiabetes, 86.5% female.Participants recruitedonline.

Aim: to examine thefeasibility and culturalappropriateness of theStanford InternetDiabetes Self-Management Work-shop (IDSMW) with AI/AN population.Method: Mixedmethods processevaluation.

A 6-week peer-ledinternet-based work-shop covering nutri-tion, complications,medications and man-aging emotions. Partic-ipants log in threetimes/week for 2 h in-cluding reading onlinecontent.

23 AI/AN participantsparticipated regularly,4 sporadically.Feedback indicatedworkshop wasculturally acceptablebecause of theparticipation of AI/ANpeople, and that all AI/AN discussion groupswere preferred.

The intervention isadaptable due to apeer-led mechanism ofdelivery. It was consid-ered culturally appro-priate with limitedadaptation. Participa-tory approaches to re-cruitment facilitatedimplementation.

It is feasible toimplement anInternet-delivered dis-ease self-managementworkshop within a di-verse AI/AN popula-tion. Severalparticipants volun-teered to be peers infuture onlineworkshops.

Kypri (2013)NZ [28]Funding: NZAlcohol AdvisoryCouncil

N = 2355 Maoristudents aged 17-24 atseven of NZ’s 8 univer-sities were screenedfor harmful alcoholuse (AUDIT-C). Thosescreening positive (n =1789) recruited to theresearch trial. N = 850control, N = 939intervention.

Aim: to test theeffectiveness of a web-based alcohol screen-ing and brief interven-tion (e-SBINZ) forhazardous drinkingMethod: Parallel,double-blind, multi-site, randomised con-trolled trial. Follow-upquestionnaire 5months post-randomisation.

Web-based alcoholassessment andpersonalised feedbackon health risks, otherrisks, expenditure andcomparative data, aswell as tips to reduceharm. The interventiontook <10 min postscreening.

Relative to controls,participants receivingintervention drank lessoften, less per drinkingoccasion, less overalland had feweracademic problems.These differences werestatistically significant.

It is possible to reachlarge numbers ofMaori people withhazardous drinking viathe internet. E-SBINZ isextremely low cost.Personalised feedbackavoided framing Maoristudent drinking interms of deficit.

e-SBINZ reducedhazardous and harmfuldrinking amongst non-help seeking Maoristudents and has thepotential to lead toongoing public healthbenefit in the longterm, especially withannual implementa-tion in all new Zealanduniversities. Furthergeneralisability notclear.

Levine (2009) [20]USA:Funding: US Army.COI: 2 authorsown stock (<5%)in the company

N = 109 AN (>18years) with type 1 & 2diabetes mellitusrecruited via IndianHealth Centers inAlabama, Idaho, and

Aim: To test whetherinteraction with aweb-based diabetesmanagement app:(MyCareTeam®) in-creased monitoring of

The app that providedfeedback on bloodglucose levels,culturally adaptedinformation, andfacilitated timely

Use of the app varied,with 46/109 using it 2/month. The moreparticipants used theapp, the more theytested their BG and

One of the keymechanisms by whichthe app worked wasincreasing the sense ofcloseness between thepatient and HCP,

Use of the appencouraged HCP-patient interaction andpatient-centred com-munication, which inturn increased BG









that has licensedMyCareTeamtechnology.

Arizona. Gender/agenot reported.

blood glucose (BG)levels and health careprovider (HCP)interaction.Method: non-randomised prospect-ive feasibility study.

interaction betweenpatients and HCPsthrough textmessaging.

interacted with theirHCP. The messagesfrom HCPs seemed tohelp motivate use ofthe app.

increasing trust andaccountability. Theauthors suggest thatapps without thispersonal element maynot be as effective.

monitoring. Authorssuggest further re-search on the relation-ship betweenmessaging and clinicalhealth benefits.

Montag (2015)[21]USAFunding: NationalInstitute ofGeneral MedicalSciences

N = 263 AI/AN womenof child-bearing age inSouthern California, re-cruited via healthclinics. N = 121 inter-vention N = 142 con-trol (TAU)

Aim: to assess theeffectiveness of SBIRTat reducing riskydrinking and risk ofalcohol-exposed preg-nancies (AEP).Method: Randomisedtrial with follow-upquestionnaires at 1, 3and 6 months.

SBIRT was an adaptedfrom eCHECKUP TOGO, a brief (20 min)interventioncomprising: web-based survey with per-sonalised feedback in-cluding analysis of risk,and helpful advice thatcould be printed outconfidentially.

No difference betweenintervention andcontrol groups. Riskydrinking decreased inboth groups: drinks/week, (p < 0.001);frequency bingeepisodes/2 weeks, (p =0.017) and risk of AEP(p < 0.001) at 6months postintervention.

Baseline factorsassociated withdecreased alcoholconsumption atfollow-up included thethinking other womengroup drink more,more binge episodesin the past 2 weeks,needing treatment fordepression.

Null finding suggeststhat assessment alone,without intervention,may be enough todecrease risky drinkingand vulnerability toAEP. Contraceptivecould be added tofuture interventions toreduce vulnerability toAEP.

Phillips (2014) [40]AustraliaFunding:AustralianGovernmentDepartment ofhealth and AgeingHearing LossPreventionProgram.

N = 53 (30intervention, 23control) caregivers ofAboriginal childrenliving in remotecommunityhouseholds in NT, withaccess to a mobilephone in thehousehold.

Aim: To test whetherWBTI for families ofchildren with tympanicmembrane perforation(TMP): (i) increasedclinic attendance, (ii)improved ear healthand (iii) provided aculturally appropriatemethod of healthpromotion.Method: multi-centre,parallel group, RCT.

One ear healthMultimedia MediaService (MMS) in thelocal Indigenouslanguage sent every 4days, ±24 h windowover 6 weeks. Videoswere short, animationsof Indigenous rolemodels, accompaniedby personalised textmessages in Englishwith a prompt to visitthe clinic.

No significantdifference betweengroups in clinic visitsper child, healedperforation, middle eardischarge orperforation size.Majority were happyto receive themessages. Ten familiesin the interventiongroup reported notreceiving themessages.

Culturally appropriateMMS that could beshared amongstfamilies, the videomessages may havebeen unclear orconfusing, and simpletext messages may bemore effective. Uptakewas impacted byevents in thecommunity unrelatedto the trial.

Mobile phone-basedMMS and text messa-ging intervention wasacceptable, but it hadno short-term impacton clinic attendance orear health. A studyover a longer timeperiod may be moreinformative 4`.

Povey (2016) [41]AustraliaFunding: NorthernTerritory (NT)Department ofHealth

N = 9 (3 male; 18–60years old) Aboriginaland Torres StraitIslander communitymembers withoutserious mental illnessin Darwin, NT.

Aim: To exploreacceptability of twoculturally responsive e-mental health apps.Method: 3 3-h focusgroups. Transcriptswere member-checkedand analysedthematically.

The AIMhi Stay StrongiPad app is a clinician-assisted therapeuticgoal setting tool.iBobbly is a self-helpsuicide prevention appfor mobile devicebased on acceptancecommitment therapy.

Findings indicated thatacceptability wasinfluenced bycharacteristics of theperson (e.g. mentalhealth), environment(e.g. stigma) and apps(e.g. ease of use.

Uptake and use werereportedly influencedby motivation tochange; technologicalcompetence; literacyand language; internetor phone access; freedownload; ease ofnavigation; culturalrelevance, voices,animations.

E-mental health toolscan improve thewellbeing ofIndigenous people.There was strongsupport for theconcept of e-mentalhealth apps and opti-mism for their poten-tial. Specificadaptations may aiduptake.

Raghupathy (2012)[22]USAFunding: NationalInstitute on DrugAbuse

Rural and urban AI/ANyouth, other serviceproviders and artistscollaborated on thedevelopment processin northern California.N = 45 AI/AN youthaged 11-13 partici-pated in the finalreview.

Aim: To describe theadaptation of a drugpreventionintervention into alow-cost computer-based drug preventionintervention: Honour-ing Ancient Wisdomand Knowledge(HAWK2)Method: Descriptivereview ofdevelopment process

HAWK2 comprised 7lessons, 25–30 mineach, which could beimplemented flexibly.Total exposure 3.5 h.Evaluation at the endof each lesson

In the final reviewwith, HAWK2 receivedhigh mean ratings onlikeability (4.8/5), easeof use (4.5/5),comprehension (4.6/5),and future use (5.0/5).Practitioners also gavepositive feedback.

Strengths were:Recognising theinfluence of specificcultural and contextualvariables; building onan existing evidence-based program; andIntegrating communityperspectives.

Computer-basedinterventions are acost-effective way ofengaging youth inprevention program-ming. Future studies ofeffectiveness and feasi-bility are needed.

Ram (2014) [29]NZFunding: AsthmaFoundation of NZ

N = 761 consecutivepatients and 18 nursesin primary care. N = 44were Maori patients, n= 18 Pacifica. Ageranged from 5 to 64 inthe Waitemata regionof Auckland.

Aim: To evaluate theeffectiveness of theonline intervention atreducing exacerbations,hospital admissions andemergencypresentations, use ofcorticosteroids andbronchodilator reliance.Method: Retrospectivecohort study. Patientdata were comparedpre-post intervention.

GASP is an onlinedecision support toolfor primary care,providing serviceproviders with skills &knowledge toundertake a structuredasthma assessment.The GASP tool is alsoshown to patients.

Maori and Pacificapatients showed asignificant decrease inED presentations butno differences in riskof exacerbations, useof other treatments orhospital admissions.Asian and NZEuropean patientsshowed benefit on allmeasured outcomes.

The difference inbenefit may beattributed to thesignificantly greaterburden of respiratoryillness in Maori andPacifica and Maoripopulations, includinga hospital admissionrate twice that of NewZealand Europeans.

GASP in primary carehas the potential totranslate intosignificant clinicalimprovements for butits potential for use inMaori and Pacificapopulations needs tobe further explored.









Riddell (2007) [30]NZFunding: HealthResearch Councilof NZ; NationalHeart Foundation

N = 19,164: Maori =1450 (7%). Mean age:53.2, 46% female.Participants attended“ProCare” primaryhealth care providersin Auckland.

Aim: To describe thecardiovascular disease(CVD) risk factor statusand risk managementof Maori vs non-Maoriusing PREDICT-CVDMethod: Patientsopportunisticallyassessed in routineprimary care practice.

PREDICT-CVD is a web-based clinical decisionsupport programmefor CVD risk assess-ment and manage-ment. It has beenshown to increaseCVD risk assessmentrates in primary care.

Maori were assessed 3years younger thannon-Maori. Maori withCVD received moreanti-coagulants, BP-lowering and lipid-lowering medications.Maori with Ischemicheart disease were halfas likely to have arevascularisationprocedure.

An electronic decisionsupport programmegenerated CVD riskburden and riskmanagement data forMaori and non-Maoripopulations in routineclinical practice in real-time.

When Maori specificequations replacethose based on awhite, middle-classAmerican population,the PREDICT-CVD willprovide a world-classdata system that canidentify gaps in carefor Maori patients andenable action onthem.

Robertson (2007)[23]USAFunding: SouthDakota StateUniversityFoundation

N = 52 Lakota SiouxAN with type 2diabetes individuals(33 intervention group,19 controls), living onNorthern Plains IndianReservation, SiouxFalls, South Dakota.

Aim: To develop andtest a culturallyappropriate web-based interactiveprogramme (KeyaTracker) for manage-ment of type 2diabetes.Method: Randomisedcontrol trial. Pre-postdata collected onHbA1c, exercise, diet,cultural activities, andsocial activities.

Kaya Tracker was aninteractive websitedeveloped with inputfrom tribal Elders.Content coverednutrition, physicalactivity, social andcultural activities.Participants logged-in3 times per week for24 weeks.

HbA1c controlimproved in theintervention grouprelative to controls (p= .025), suggestingimproved diseasecontrol andprogrammeeffectiveness. Fourparticipants did notcomplete theintervention.

Effectiveness may bedue to the flexibility ofthe online delivery.Also, the website wasdesigned for itsaudience, thereforeaccounting for LakotaSioux understandingsof health.

Use of a culturallyappropriate Web-based interactiveprogramme may be aviable tool to assesswith diabetes-relatedlifestyle change. A lar-ger study is warranted.

Shepherd (2015)[31]NZFunding: NZMinistry of Health;Rotary Club ofDowntownAuckland;University ofAuckland. COI: 2authors havefinancial interest inSPARX.

N = 26 Māori people,taitamariki(adolescents);taitamariki mothers(aged 16–18); andwhanau (family) inAuckland.

Aim: To describeexperiences of aprototypecomputerised therapyprogramme fortreating mild tomoderate depression.Method: Mixedmethod KaupapaMaori research. 7 focusgroups followed by asurvey. GeneralInductive/thematicanalysis was used togenerate themes.

Smart, Positive, Active,Realistic, X-factorthoughts (SPARX) pro-vides free, compu-terised (cCBT); onlinecomputer programmeusing avatars. Playersare led through 7 fan-tasy “realms” each last-ing 30–40 min. 1–2levels completed over3–7 weeks.

Good face validity;cultural relevance forMaori; Whanau areimportant for youngpeople’s wellbeing.Ideas for improvementrelated to use ofclinical and Maorilanguage, reducingtext, and using audio.

Positive evaluation andacceptance were aidedby cultural relevanceof both process andcontent. Culturallyadapted mental healthinterventions arethought to be muchmore effective.

Participants supportedthe contemporaryMaori design of theprogram. SPARX wasthe first programme ofits kind and may beused as a model forother cCBTinterventions.

Shepherd (2018)[32]NZFunding: NZMinistry of Health;Rotary Club ofDowntownAuckland;University ofAuckland; Te RauMatatini

N = 6 Māori taitamariki(adolescents) aged 14-16 (mean 14.6), in twoschools in the widerAuckland area. Partici-pants had mild-moderate depressionand low risk for self-harm.

Aim: To exploreadolescents’ opinionsabout a programmefor treating mild/moderate depressionin young peopleMethod: Exploratoryqualitative study usingsemi-structured inter-views. Thematicanalysis.

The SPARXprogramme is anonline, gamified cCBTprogramme usingavatars for treatingmild – moderatedepression.

Themes indicated that:(1) the programmewas helpful because ittaught CBT skills; (2) Itwas engaging due toMaori designs; (3) Thecharacters providedhelpful advice; (4) Itwas both enjoyableand challenging; 5)Writing thoughts andfeelings was helpful.

Māori designsappeared beneficial, asthis seemed toenhance culturalidentity. SPARX waslike a computer gamethat could help withdepression. Abreathing relaxationexercise was valued

Māori designs wereappropriate and useful.The ability tocustomise thecharacters with Māorienhanced culturalidentity. A much largerstudy should beconducted to explorethe efficacy of SPARX.

Starks (2015) [24]USAFunding: Patient-Centred OutcomesResearch Institute

Multiple groups ofstakeholders consultedwithin South CentralAlaska NativeFoundation had inputinto tool development.N = 20 patients and 7service providersparticipated in pilotingthe tool.

Aim: To report on themulti-year stakeholderengagement processfor the developmentof the patient-centred“Depression Manage-ment – Decision Sup-port Tool (DM-DST)”.Method: Qualitativeanalysis of multipledata sources includinginterviews withpatients and providers,meeting notes,consultations and pilottesting.

Electronic, patient-centred, depressionmanagement decisionsupport tool (DM-DST)with two components:an interactive tool tofacilitate discussionsbetween patients andproviders and a web-site with detailed infor-mation for patients.

Stakeholderengagement resultedin substantialmodification of theoriginal tool, includingbreaking it into twoparts, incorporating ANimagery and culturalconcepts includingfaith, family andcultural expressions ofdepression andsolutions. There was afocus on reducingstigma.

Multi-stakeholderengaged researchallowed theresearchers tounderstand the diversevalues and needs ofend-users. The toolwas considered inter-esting, useful, andthought-provokingwith the potential tofoster conversationswith primary careproviders.

The process employedas relevance to otherprimary care systemsseeking to improveand individualisetreatments. The toolenhances patient-centred decision mak-ing. Future researchwill test its effective-ness is an RCT.









Taualii (2010) [25]USAFunding: Spirit ofEagles SpecialPopulationsNetwork (NIH)

N = 25 urbanAmerican AI/ANyoung people, agedfrom 12-18 in Seattle.

Aim: To adapt, modifyand test for useabilityan existing smokingprevention andcessation resource.Methods: Focusgroups wereconducted in 2phases, first to adaptand then to test theusability of theSmokingZine website.

SmokingZine an e-health website target-ing behaviour changerelating to youthsmoking preventionand cessation.

Participants werereceptive to the use ofthe intervention tooland offered ideas forchanges to make itmore culturallyrelevant. In phase 2,participants found thesite easy to use andrelevant to smokingcessation.

There was a lot ofoverlap betweenmainstream and AI/ANyouth perspectives onsmoking. Includingcultural distinctions ina new website wasacceptable and valued,although computeraccess not ubiquitous.

These findings providejustification for a full-scale trial of the Smo-kingZine website. Fu-ture research shouldinclude both urbanand rural AI/AN youthand consider deliverythrough schools.

Tighe (2017) [42]AustraliaFunding:AustralianGovernmentDepartment ofHealth and Ageing

N = 62 young men(22, 36%) and women(aged 18–35 years) inremote communitiesin the Kimberleyregion of north-Western Australia. 4were non-Aboriginal,the remainder wereAboriginal and/orTorres Strait Islander.

Aim: To evaluate theeffectiveness of a self-help mobile app forsuicide prevention.Method: Randomisedwaitlist control trial.Measures were takenface-to-face at baselineand after the interven-tion for both groups.The control group hada final follow-up as-sessment at 12 weeks.

iBobbly was a mobileapp that targetssuicidal ideation,depression,psychological distressand impulsivity usingAcceptanceCommitment Therapyapproaches. Threecontent modules andthree self-assessments,completed over 6weeks.

Data were available for40 participants.Significant pre/postchanges on suicideideation in the iBobblyarm (p = 0.0195), butnot when comparedwith waitlist arm.iBobbly group showedreductions indepression anddistress scorescompared withwaitlist. Waitlistimproved after 6weeks of app use.

Uptake was aided bythe collaborativedevelopment process.Acceptance wasindicated by thepromotion of the appby the targetcommunity. Technical/connectivity failureprevented some fromproviding final data.

The app, usingacceptance-basedtherapy reduced dis-tress and depressionbut did not show sig-nificant reductions onsuicide ideation or im-pulsivity. Studyhighlighted the im-portance of co-design.

Tonkin (2017) [45]AustraliaFunding: NHMRC;National HeartFoundation; NTGovernmentDepartment ofHealth

N = 36 smartphoneusers (aged 18–35years) in two remoteIndigenouscommunities in NT.There were 10participants percommunity in eachphase of research.

Aim: To develop andtest a prototype appto improve nutritionalintake relating tosugar-sweetened bev-erages (SSB).Method: Formativephase includedsimulated groceryselection activity, semi-structured interview,and survey. End-usertesting phase involveda “think aloud” testand interview on usersatisfaction.

Self-administeredSmartphone appincluding assessmentand feedback on SSBintake, behaviouralchallenges, interactiveexercises and games.

Drivers of food choice/behaviour includedtaste, family, health,price and convenience.Mixed methods dataon usability indicatedthat participants foundthe app useful & wereconfident using it, withsome suggestedmodifications.

Complex set-up andlog-in inhibit use. Dis-semination of appsshould be contextuallyembedded with manyavenues available.Learnings about thesocial dynamics of re-mote communities inthis study may haverelevance to other dis-advantagedcommunities.

Recommendationsincluded: formativeresearch needs to beprioritised in projectplans; use mixedmethods; patterns oftechnology use maybe different indifferent locations;include non-writtencommunication; locallanguage; engaginggraphics.

Verbiest (2018)[33]NZFunding: HealthierLives He OrangaHauora NationalScience Challenge

Partnership betweenMaori, Pasifika andEuropean academics,Maori health providersand communitymembers inWellington andAuckland regions.

Aim: (a) to provideoverview of co-designmethods and pro-cesses; (b) to describehow co-design wasused to select behav-ioural determinantsand changetechniques.Method: 6-step partici-patory co-designprocess conductedover 11 months. Focusgroups, photographs,notes and observa-tions were thematicallyanalysed.

Self-administeredmHealth tool(smartphone app) forprevention of non-communicable disease,incorporating contem-porary Maori and Pasi-fika theoreticalframeworks of healthand health promotion.

Domains prioritised: (a)physical activity, (b)family, and (c) healthyeating (including fruitand vegetablegardening; Table 1).Māori communitypartners identifiedadditional ethnic-specific themes rele-vant for overall Māorihealth and wellbeing.

By using ethnic-specific models ofhealth for interpretingthe co-design data,the selected behav-ioural barriers, en-ablers, and changetechniques align withthe cultural needs andwants of the user.

Authors suggest futuretailored, lifestylesupport (mHealth)interventions forIndigenous and otherpriority groups shouldbe co-designed andlook beyond Westernapproaches to ensurethey are evidence-based and culturallyrelevant.

Whittaker (2006)[34]NZFunding:Waitemata DistrictHealth Board;Future Forum;National HeartFoundation

80 GeneralPractitioners (GPs)providing care toMaori and non-Maoripeople in New Zea-land. N = 474 (28.2%)Maori patients pre-and n = 484 (25.7%)postintervention.

Aim: To determine ifan electronicassessment andmanagement tool forCVD could increaserisk assessment butnot inequalities.Method: Retrospectiveaudit of GPs using thetool’s electronicmedical records (EMRs)

PREDICT-CVD is a web-based decision supporttool to facilitate risk as-sessment for GPs touse in the manage-ment of CVD in pri-mary care.

Maori participantswere significantlydifferent from non-Maori on all measuredparameters. Maoriwere younger, hadmore diabetes, lowerSES and higher rate ofsmoking. Rate of riskassessment increasedin both groups.

Rates of documentedrisk assessment werelow overall. 7.2% ofaudited EMRs had noethnicity stated andcoded as non-Maori,which may have re-sulted in under- count-ing of Maori.

The implementation ofthe tool should notoccur without animplementationprogram, and otherchanges to increaseresponsiveness to theneeds of those at riskof CVD, such as takingrisk assessment intocommunity settings.


availability of infrastructure [15, 23, 39–41], underlyingburden of disease [29] and funding to reduce the cost toend-users [31, 41].

Recommendations and conclusions from the sourcesCulturally appropriate, evidence-based WBTI have thepotential to improve mental health [27, 32, 42], addresssubstance abuse treatment barriers [16], improve self-efficacy and self-management in healthcare [23, 26] andreduce inequalities in access to healthcare services, forIndigenous communities. WBTI are a cost-effectivemethod of delivering information and engaging targetpopulations, such as youth [22, 28] and pregnant women[18], to reduce hazardous and harmful alcohol intake. Infact, one source reported that using a WBTI to self-assess risky drinking behaviour may be enough to influ-ence behavioural change, without implementation of anintervention [21].Thus far, evaluations of smoking cessation WBTI for

Indigenous populations have been limited to America[15, 25]. These evaluations concluded that additionallong-term, rigorous research is needed to assess WBTIapproaches to keep American Indian and Alaskan Nativeyouth from becoming regular smokers [15] and that fu-ture research needs to include both urban and rural In-digenous youth [25], highlighting that to date no onlinetobacco programmes have been designed specifically forthese populations [15].Sources that evaluated the use of mental health WBTI

for Indigenous populations concluded that these inter-ventions are likely to be important in overcoming pooraccess to services for remote communities [39, 43], orfor youth that might be reluctant to engage in traditionalhealth services [27]. Further, developing WBTI in part-nership with Indigenous communities ensures culturallyappropriate interventions that are accepted and pro-moted by the communities [24, 31–33, 42, 44], and leadto improved wellbeing of Indigenous people [41]. Inaddition, improved access to culturally appropriateWBTI tools, and training in how to use these tools, al-lows mental health workers to better support their Indi-genous clients [36, 37, 39].Cardiovascular disease risk data for Maori people can

be successfully generated in real time through the use ofan electronic decision support tool [30]. In addition, car-diac rehabilitation care delivered through WBTI plat-form has the potential to significantly improve outcomesfor Indigenous populations [38]. However, other re-searchers suggest that the use of WBTI for cardiac careshould not occur in isolation, instead emphasising thatWBTI should be complemented by a comprehensivecare program [34].Implementing culturally appropriate WBTI for the self-

management of diabetes has been shown to be feasible

[19]. The use of such platforms has been shown to im-prove diabetes control in Indigenous populations [23],possibly because these interventions may increase the fre-quency patients monitor their blood glucose levels [20].The remainder of sources identified for inclusion in

this review also recommended WBTI as positively sup-porting Indigenous communities. WBTI were shown tohave the potential to be a useful tool for dieticians work-ing to optimise the food and nutrient intakes of preg-nant women [35] and may reduce sudden unexpectedinfant deaths by increasing education beyond traditionalface-to-face delivery methods [26]. Research demon-strated the importance of designing culturally appropri-ate WBTI to promote health through understanding anduse of natural resources [17], to increase ear healthknowledge [40] and to improve asthma education [29].

DiscussionThe purpose of this review was to identify and describethe available international scientific evidence on WBTIused by Indigenous peoples in Australia, New Zealand,Canada and USA for managing and treating health con-ditions. As mobile devices, including smart phones, be-come ubiquitous in the general population, web-basedand other electronic interventions are increasing innumber and scope. This is indicated by an increase instudies on the topic year on year, and of the many pro-tocols that were excluded from this scoping review, butwhich clearly indicate a growing field with many studiesplanned or underway. The results indicate that whileWBTI are most commonly designed to manage mentalhealth and substance use issues, they are increasingly be-ing incorporated in the range of treatment and supportoptions for a variety of health conditions and are beingused by those with the health condition or by serviceproviders.The popularity of WBTI stems in part from their po-

tential reach, which extends to anyone in any geograph-ical location or social context where they have access tothe internet and a device capable of running the pro-gram. While increases in internet access amongst Indi-genous populations in Australia, New Zealand, Canadaand USA have been reported, in each of these countries,a “digital divide” across ethnic and geographical linesalso exists, with Indigenous households and individualshaving less access to the internet overall, and internetaccess being lowest in those geographical areas with thehighest proportion of Indigenous residents [46]. The lackof any studies from Canada meeting the inclusion cri-teria was surprising, however there is evidence that otherforms of ICT, such as telehealth, are in use in Canada,and that First Nations communities are engaging withand developing digital health technologies in line withIndigenous models of health and wellbeing [47].


The available data indicates that young people tend tohave greater internet access and use [48] so it is perhapsnot surprising that adolescents or young people were thefocus of a large proportion of studies (8/34). Indigenouspopulations in Australia, USA, Canada and New Zealandare younger than the general populations in each coun-try [46, 49–51], so interventions designed to improve thewellbeing of young people are particularly relevant.However, there were several studies of WBTI focusingon chronic diseases such as diabetes and cardiovasculardisease that are relevant to older people.Perhaps the most common and clear lesson articulated

by study authors was the importance of developing pro-grammes in collaboration with the target communities.In this sense, WBTI are no different to other interven-tions, with issues of governance and ownership beingcentral not only to the ethical delivery of programmesbut also to their acceptability, feasibility and effective-ness. Several authors cited “co-design” or collaborativedesign as strengths of their projects. Having the targetcommunity involved in all aspects of intervention andstudy design is in line with ethical guidelines for re-search with Indigenous peoples internationally [52–55].Meta-analysis of effectiveness was beyond the remit of

this scoping review, and while such analysis is likely tobe limited by the small sample sizes evident in thesestudies, future research could usefully examine both theeffectiveness and cost-effectiveness of WBTI with Indi-genous people. Cost-effectiveness is frequentlyhighlighted as an advantage of WBTI. However, fewstudies include analysis of cost-effectiveness that incor-porates the often-substantial costs of development thatmay occur over lengthy time periods. This scoping re-view was limited in the degree to which it could examinebarriers to accessing WBTI resulting from cultural andlinguistic diversity, low health literacy, limited digitalcapabilities and infrastructural and resource limitationsfor individuals and communities in different geographiclocations. This review is also based on a definition ofhealth that is less holistic and relational than Indigenousmodels of health and wellbeing tend to be [1]. Future re-search could focus more explicitly on a broader range ofsocial health factors, such as language use and reclam-ation, as these are likely to have health benefit from anIndigenous perspective [56]. Broadening the review toinclude digital sources, such as app stores and socialmedia, could also provide a more comprehensive ac-count of all indigenous-focused WBTI and tools, al-though formal evaluations of such interventions, whichare the focus of this review, are unlikely to be sourcedthis way.As mobile digital devices become cheaper and more

widespread, and internet technology improves in speedand geographic coverage, it seems safe to assume that

WBTI will also become more widespread, and of interestto health services and commercial entities who may wishto exploit potential markets. This is true for Indigenouspeoples as it is for others, although the smaller popula-tion size may limit commercial interest in Indigenous-specific WBTI and explain the propensity of fundingfrom government rather than commercial sources. Asthe field grows, ensuring that technologies accessed inIndigenous communities are high quality, evidence-based, culturally appropriate, inclusive and accessiblewill require that we continue to examine and re-examinethe evidence as it emerges and that Aboriginal commu-nities continue to lead the development of technologiesthat best meet their needs.

Supplementary informationSupplementary information accompanies this paper at https://doi.org/10.1186/s13643-020-01374-x.

Additional file 1. Preferred Reporting Items for Systematic reviews andMeta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist.

AcknowledgementsThe authors would like to thank Maureen Bell, Research Librarian at theUniversity of Adelaide, for her assistance with the development of the searchstrategy, and Frida Svensson for her excellent project management. Thisresearch was conducted as part of a National Health and Medical ResearchCouncil funded project (#APP1100696). JW is Sylvia and Charles Viertel SeniorMedical Research Fellow.

Authors’ contributionsRR, SH, CT developed and tested search terms. RR conducted the searchesand was primary reviewer. IF, SH, CT, OP and JW contributed to secondaryreview and data extraction. JM and JS assited with data charting andsummarising. RR drafted the final manuscript with JS and JM, and all authorsread and approved the final manuscript.

Competing interestsThe authors declare that they have no competing interests.

Author details1Aboriginal Health Equity, South Australian Health and Medical ResearchInstitute, Adelaide, South Australia, Australia. 2College of Medicine and PublicHealth, Flinders University, Bedford Park, South Australia, Australia. 3School ofMedicine, University of Adelaide, Adelaide, Australia. 4Rosemary Bryant AOResearch Centre, Clinical and Health Sciences, University of South Australia,Adelaide, South Australia, Australia. 5Australian Institute of Health Innovation,Macquarie University, Sydney, New South Wales, Australia. 6Institute of UrbanIndigenous Health, Windsor, Queensland, Australia.

Received: 18 December 2019 Accepted: 28 April 2020

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