Could electronic information systems enhance the quality of Aboriginal health promotion? Findings of an audit of Aboriginal health programs in the Northern Territory of Australia

Background: In Australia, health services are seeking innovative ways to utilize data available in electronic patient information systems, such as Electronic Health Records, to report on, and improve, the quality of health care delivery and health system performance for Aboriginal Australians. These systems provide a valuable source of information on delivery of health care to individuals but are rarely designed for community-level health services, such as health promotion and disease prevention projects. Therefore, research about the use of information systems in health promotion and the potential to report on health promotion quality has received little attention in the academic literature. This study utilizes data stored in a specifically designed, commercially available, health promotion information system (QIPPS) to examine the potential for reporting and improving Aboriginal health promotion. Methods: A structured audit tool was used to extract information from a sample of 39 health promotion projects delivered between 2013 and 2016 in Aboriginal communities of the Northern Territory. Project level data were aggregated and reported as best practice indicators of Aboriginal health promotion quality. Qualitative text describing community participation in health promotion were also captured. Results: QIPPS provided an organized data source on a vast array of health promotion project information for secondary analysis. Using a structured data collection tool enabled project level information to be aggregated at a system-wide level and identified gaps in quality indicators. Information about some aspects of health promotion, like community participation in project planning, was described in

detail such that it could be used for quality improvement purposes, however, information about other areas, particularly during project implementation and evaluation, was limited.
Conclusion: Project information stored in a specifically designed health promotion electronic information systems can be used to report on and improve Aboriginal health promotion efforts. Data availability and quality were limiting factors for reporting health promotion quality. Strategies to improve the quality and accuracy of data entry together with the use of quality improvement approaches are needed to reap the potential benefits of health promotion information systems. BACKGROUND Australia's health system is under increasing pressure to perform better at 'closing the gap' in health disparities between Aboriginal and Torres Strait Islander peoples and Australians of other descent (1) (Hereafter, we use "Aboriginal" as a collective term, acknowledging the diversity of language and culture of Aboriginal and Torres Strait Islander peoples, as the First People and custodians of Australia). This has stimulated wide-spread uptake of quality improvement programs and the introduction of key performance indicator reporting, and a rapidly expanding quest for better information about the quality of health services and programs for Aboriginal people (2). Reports on health care quality and health system performance, however, repeatedly lack information about the quality and effectiveness of Aboriginal health promotion programs and services. For example, health promotion -described as 'activities designed to improve or protect health within social, physical, economic and political contexts'(3) -is one of 68 performance measures included in the Australian Government's Aboriginal and Torres Strait Islander Health Performance Framework. Monitoring performance of this measure is based on the number of health promotion interventions provided by clinicians and other health professionals. Information on quality and/or health promotion effectiveness is not reported due to limits in data quality and suitable methods for measuring the nature, level and reach of programs and activities (3).
In addition to improving reporting of the contribution that Aboriginal health promotion makes to 'closing the gap', there are calls for Aboriginal people and communities to become active partners in their health care delivery (4,5).
Community involvement, engagement and control has long been argued as 'what works to overcome Aboriginal disadvantage' and an essential factor that underpins successful programs for Aboriginal Australians (6). Studies evaluating community participation in health promotion and community development projects, have consistently concluded that involvement of communities enhances delivery and uptake of health programs (7,8), however, descriptions about the approach, strategies and processes of community engagement i.e. how the community is engaged, where, and who participated, remains limited (9, 10).
Electronic information systems have the potential to overcome some of these information challenges and could promote the visibility of Aboriginal health promotion (11). Firstly, by facilitating collection, documentation and organization of a vast array of information about health promotion in a structured and systematic way. Secondly, as a source of data to be analyzed and communicated in real-time for quality improvement and performance indicator reporting purposes. In the clinical setting, Electronic Health Records (EHRs), a type of electronic information system commonly used in health services, provide a valuable source of information about the delivery of health care to individuals. Indeed, health services have sought innovative ways to utilize data available in these systems to report on, and improve, the quality of health care delivery and health system performance for Aboriginal Australians (12,13). EHRs and other types of patient information management systems, however, are rarely designed or developed to track and monitor delivery of population-level health services, such as health promotion and disease prevention programs. While there is growing evidence to suggest health promotion and prevention could similarly benefit from like information technologies (11,14) , research about the use of these systems and their potential to improve quality of health promotion, generally (15), or in the context of Aboriginal communities, specifically, has received little attention in the academic literature. This is because systems for recording and monitoring health promotion efforts are often created for individual organization's internal purposes, without any record of how it was designed, used or lessons learned, and therefore is rarely discussed or evaluated in the literature.
Within this broader context, we report a study of Australia's first investigation of how health promotion data stored in an online information system could be used to report on, and improve, the quality of Aboriginal health promotion. Between 2008 and 2019, the Quality Improvement Program Planning System (QIPPS), a commercially available online data management system, has been the centralized system for Northern Territory Health (NT Health) staff to document their health promotion efforts. Thus, QIPPS provides a valuable, yet relatively unexplored data source about health promotion practice in Aboriginal communities. In this study, we were interested in the potential of utilizing health promotion data captured via QIPPS for the purposes of quality improvement and performance indicator reporting in Aboriginal health promotion, with an emphasis on how community are engaged in health promotion. To do so, we undertook an exploratory analysis of QIPPS data to (1) describe the scope of Aboriginal health promotion programs in the NT; (2) assess the quality of health promotion planning, delivery and evaluation, and their documentation in QIPPS; and (3) examine the extent to which community participation is recorded such that it could be used for quality improvement and performance reporting purposes.

Improving Aboriginal health promotion in the Northern Territory
The NT is arguably Australia's most challenging health service delivery environment. The NT has the highest proportion of Aboriginal Australian residents.
Approximately 30% of the total NT population identify as being Aboriginal and/or Torres Strait Islander peoples compared to 3% of the total Australian population (16), making NT Health the single largest provider of health services to Aboriginal peoples in Australia. About 90% of the NT Aboriginal population live in discrete, remote communities, where the delivery of health care is logistically challenging, hence more expensive, than in urban settings (17). The gap in life expectancy between Aboriginal peoples and Australians of other descent is greater in the NT (14.4yrs for both males and females compared to 10.6 years for males and 9.5 years for females, nationally), and is increasing over time (3). Colonization, social determinants, and discrimination are important factors in these inequities (3,6,16), as are potentially preventable chronic diseases -the greatest contributor to the difference in health status between Aboriginal peoples and non-Aboriginal Australians (16). In the NT, the Aboriginal population experience a disproportionate burden of chronic disease linked to inactivity, malnutrition, socio-economic disadvantage and access to primary health care services (3,18). The cost of the Aboriginal health gap in the NT has been estimated at $16.7 billion (19).
The critical role of health promotion and prevention in addressing these inequities and improving Aboriginal health outcomes is widely recognized in the NT. Health promotion is a core function in models of comprehensive primary health care (20) and an ongoing strategic priority of NT Health (17,21). However, in reality, a range of challenges influence health promotion delivery and its success in the NT, including the burden of acute care in Aboriginal communities, high workforce turnover, low stability and acute-oriented, temporary staffing (18,22) together with the availability of information about, and capacity to report on, community level health promotion practice (9,23,24).
To overcome some of these challenges, and to improve the quality and effectiveness of health promotion, NT Health has introduced over the past 10 years a range of initiatives. These have included: (i) a Health Promotion Strategic Framework (25); (ii) introduction of the Quality Improvement Program Planning System (QIPPS); and (iii) strong and sustained participation in continuous quality improvement initiatives (26), including in health promotion specifically (27). NT Health has subscribed to QIPPS since 2008 with the original intent of (i) assisting staff to design and deliver health promotion projects, and (ii) to support staff in documenting their health promotion efforts in a systematic and structured way.

Quality Improvement Program Planning System (QIPPS)
QIPPS was an Australian designed online health promotion tool that provided a systematic and standardized approach to health promotion project planning and evaluation. It provided a framework for people working in the health sector to plan, evaluate, share and report on their health promotion and community development projects. The platform included a wide range of supportive information, definitions, research material, references, website links and models that assisted in designing program plans and evaluations. It was also a mechanism for knowledge management and collaborative planning with internal and external partners because it included functions enabling users to capture and search a growing body of community-based initiatives.
In contrast to other health promotion systems which are typically created and used within an organization (11), QIPPS was commercially available; hosted, maintained and supported by Infoxchange; a not-for-profit social enterprise with a focus on smart and creative use of technology to improve the lives of vulnerable people, driving social inclusion and creating stronger communities (see https://www.infoxchange.org/au). Organizations subscribed to QIPPS, with fees determined by number of total users. In summary, QIPPS was Australia's only feefor-service commercially available electronic information specially designed for health promotion. Unlike organization specific e-technologies, many of which are resource intensive to develop and sustain, and unsuitable or unavailable for broarder use, QIPPS provided a ready-made health promotion quality improvement system available for uptake and wide-scale implementation.

Study Design
This is a retrospective study examining information about health promotion projects centrally documented and stored in QIPPS. We sampled QIPPS records to identify projects that: addressed chronic diseases, including mental health, environmental health, and/or risk factors (smoking, alcohol, nutrition, physical activity), designed to benefit Aboriginal people, families and communities, and that were recorded in QIPPS as delivered between 2013 and 2016.

Data sources, collection and analysis
Our approach to data collection, analysis and reporting draws on a popular continuous quality improvement technique, known as audit and feedback. 'Audit and feedback' is a systematic process of gathering information about professional practice and then comparing this with explicit criteria (such as professional standards or targets) (28). The gap between assessed performance and the criteria allows health services to target efforts on areas for improvement. Audit and feedback is widely used by Aboriginal primary health care services to assess and improve health care quality (29,30), including health promotion (9,27).
We used a previously validated audit tool that is structured around five indicators of best practice that were identified by blending available best practice guidelines and practice-based evidence in Aboriginal health promotion (27). The tool includes

Territory
Our sampling process resulted in a total of 39 health promotion projects. Most projects addressed nutrition (27 projects), followed by physical activity (7 projects) and mental health (including social and emotional wellbeing) (4 projects). Almost half (19/39) of the projects were considered once off (i.e. delivered only once and not expected to be done again). Five projects were continuous (i.e. delivered on a regular basis through the year e.g. monthly or weekly); and five were described as intermittent (e.g. delivered once a year, each year). Delivery frequency was unclear for ten projects. The type of health promotion strategies was dominated by health education (23 projects), followed by community action (19), health information (18) and strategies for creating supportive environments (14). Table 1

Recording of community participation in QIPPS projects
Documentation of community participation in planning, implementation and evaluation was reported in 20 of the 39 projects (see Table 1), and predominately described at the project planning phases (identifying need (16/20) and determining strategies (11/20)). Documentary evidence of community involvement during project implementation (7/20) or evaluation (4/20) was limited. In almost half of the projects, information describing community participation was not available or in insufficient detail, despite the QIPPS prompt to record "How will the target group and community stakeholders be encouraged to actively participate and engage with the project?" Table 2 includes examples of the unstructured text derived from project documentation; illustrating how strategies and processes of community participation are described in real world practice. The main strategy by which community participation happened was via consultation processes. Common consultation methods included community meetings, focus groups, surveys and interviews as common consultation mechanisms. Some QIPPS records included more detailed descriptions of how community participated than in others.

Discussion
This exploratory analysis demonstrates the potential of utilizing health promotion data captured via an electronic information system for the purposes of quality improvement and performance indicator reporting in Aboriginal health promotion.
QIPPS provided an organized data source on a vast array of information pertaining to health promotion practice in NT Aboriginal communities. The use of a structured data collection tool enabled project level information to be systematically collected, analyzed and displayed as aggregated data at a system-wide level. The findings provided insight into the scope of health promotion projects and identified gaps in quality indicators which could be used to target system level changes and improve Aboriginal health promotion efforts.
Our findings highlighted the most common type of health promotion projects were nutrition related, and largely dominated by health education strategies. Few health promotion projects were ongoing, the majority were delivered as once-off projects.
Encouragingly, for around half of the projects in our study, information about community participation was described such that it could be used for quality improvement and performance reporting purposes. Having a range of quality indicators enabled a nuanced exploration of the different ways community participate as an 'active partner' throughout each project phase: planning, implementation and evaluation. Our findings illustrated that information about community participation were predominately descriptions of consultation processes during the planning phase. Consistent with previous health promotion studies (7, 9, 10) records of how community were engaged and who in the community participated during phases of implementation and evaluation were not documented or were in insufficient detail. Given the centrality of community participation, control and ownership to Aboriginal program success, demonstrable improvements in community participation, as well as increasing evidence of health promotion effectiveness in Aboriginal communities, could be achieved by ensuring information systems are designed to support the collection, analysis and reporting of community involvement. Our previous research demonstrated that using indicators of Aboriginal health promotion quality within a continuous quality improvement framework enhances health system capacity for recording health promotion, and subsequently the availability and quality of data (9). With further support for uptake and implementation of quality improvement in health promotion, demonstrable and sustained improvements in Aboriginal health promotion are feasible (9, 32).
As for information systems more generally (12,13,33,34), a significant constraint in realizing the potential of QIPPS is data quality. Information about some elements of health promotion, particularly related to project planning, were more readily available, and reliably collected, such as stating project goals and objectives, identifying the target group and health issues to be addressed. Meanwhile, information about aspects of project implementation and evaluation, such as strategies for community participation, evaluation methods and reporting findings, were missing or inconsistently reported and therefore, less reliably collected for secondary analysis. Records about health promotion practice predominately constitute prose-like narratives, or free text, invariably resulting in variability in documented information. From a quality improvement standpoint, data standardization is critical for creating indicators and tracking and reporting performance over time. However, in practice, important insights about the quality of Aboriginal health promotion, such as community participation processes and strategies, will likely remain invisible if information is recorded in pre-specified formats or by applying strict documentation practices. Herein lies one of many challenges in designing an information system that supports collection, analysis and reporting of data for quality improvement, alongside health professionals' planning and evaluation needs (11,14).
The extent of generalizability of our study findings should take into account: (i) data were based on recorded health promotion practice, which may underestimate breadth and depth of actual health promotion efforts; (ii) given the long-standing use of QIPPS in NT Health, the quality of data reported is likely to be better than for other Aboriginal health services and state/territory government health departments more generally in Australia.

Consent for Publication
Not applicable

Availability of data and material
The dataset analyzed during the current study are not publicly available because the information system has been decommissioned and the product is no longer available on the market. Data are however available from the corresponding author upon reasonable request and with permission of NT Health.

Competing Interests
The authors declare that we have no competing interests