Background
Indigenous Australians continue to lag behind on all health indicators: life expectancy is 15–20 years less than non-Indigenous Australians and rates of hospitalisation, poor health and quality-of-life show similar disparities [
1]. Factors such as distance from services, availability of culturally appropriate services, workforce shortages and private health insurance cover all affect access to, and the utilisation of, health services [
1]. Aboriginal Community Controlled Health Services are the preferred and most culturally appropriate organisations to deliver health services to Indigenous people [
2]. In addition to the normal range of clinical staff, they employ Aboriginal Health Workers (AHWs) who have the trust, respect and local knowledge required in promoting the health of their community through health screening and the assessment of diseases including diabetes and mental health [
3,
4]. Against this backdrop of unmet need, a not-for-profit organisation, Hands on Health Australia, has worked for 15 years in a rural Indigenous community in New South Wales to firstly establish the prevalence and types of musculoskeletal pain and associated disability [
3,
4] and secondly to introduce services and training to better manage and prevent these conditions [
5]. This involvement has, from the start, been based on the philosophy of keeping the community involved in all phases of development, implementation, and evaluation (
http://www.ahmrc.org.au/). Research in a number of Aboriginal communities [
6,
7] indicates that chiropractic and massage may, in addition to treating musculoskeletal conditions, promote self-care in ways that improve general wellbeing and positively influence other chronic illnesses. These findings accord with research in marginalised communities in Canada, which indicates that chiropractors can function well in a collaborative environment with conventional care providers, and can also effectively contribute and participate in public health initiatives [
8‐
10].
In 2004 a chiropractic service was established in a large Aboriginal community. It built on the previous years of research and extensive discussions with a community advisory group, including community leaders and medical and allied health practitioners [
11]. It was staffed by volunteer chiropractors. During the first few years, fortnightly clinics were maintained at the Durri Aboriginal Medical Service (ACMS) and an additional chiropractic service was made available at the aged-care facility of the Booroongen Djugun Aboriginal Corporation. Community and clinician consultation meetings continued to be held, and an evaluation project was designed and funded. Phase 1 of the project aimed to evaluate the establishment and development of an ongoing chiropractic programme. The evaluation was based on a Participatory Action Research (PAR) approach [
12] and was focused on establishing a sustainable, well used and high quality service. The aim of the second phase was to describe and measure the effects of chiropractic care in this community. Despite being located in one of Australia’s largest rural Aboriginal communities there were problems with securing sufficient referrals to the service and this was compounded by concerns about sustaining funding and practitioner availability. Through Phase 1 of the evaluation process, the difficulties facing the chiropractic service and the work that was needed to overcome them became more explicit, their complexities better understood and the need to rectify them more urgent.
In 2006 the eminent sociologist, Carl Mays, described the ‘normalisation process model’ that aims to understand the practical problems of embedding and evaluating new complex interventions [
13]. His approach offered a framework for organising the many tasks that confronted us – tasks that spanned difficulties in referrals, funding and building sustainability as well as the evaluation itself. This model has since been developed into a middle-range theory [
14], but we have found the model itself most useful for our purposes. There are many other models of integrative care that address how success can be achieved but they are generally reported in relation to evaluating established services rather than providing a structure for the very early development stages. For example, the excellent and widely used framework by Boon et al. (2004) will enable us to describe and evaluate our service, once it is better established, in terms of four key components of integrative health care practice - philosophy/values; structure, process and outcomes [
15]. Another framework of particular interest – that of Mior and colleagues for the integration of chiropractic services into a multidisciplinary practice in Canada [
16] – was being developed in parallel with our own work and is discussed later.
This paper describes using the normalisation process model [
13] to establish, integrate and evaluate a chiropractic service in a rural, Indigenous Australian community. In order to make it ‘fit for purpose’ in our particular context we made some adaptations, especially in relation to language and terminology. We demonstrate how an academic conceptual model can be interpreted and adapted for use in a complex practice situation.
Discussion
The concept of ‘normalisation’ or ‘embedding’ a new service focuses on the importance of sustainability. The Normalisation Process Model emphasises the importance of stability and order in health care, both within one-to-one consultations and within the organisation as a whole. In the context of an Australian Aboriginal community it directed us to consider ways to promote chiropractic as something that will enhance relationships, interactions and procedures, and avoid disrupting them. This should be achievable, given that chiropractic requires few resources and offers an alternative referral option for conditions that are difficult to treat within biomedicine. The model also emphasises the importance of chiropractors becoming trusted team members who have acceptable and recognised knowledge and skills; this is more of a challenge given the national Australian context in which chiropractors are still marginalised in healthcare organisations. Our results suggest that chiropractors should be able to find a place within a complex occupational web, by being seen to be very similar to well known occupational groups such as physiotherapists. We have been able to improve the potential for team working by providing more frequent clinics, by negotiating access to electronic and paper clinical systems and by linking into established and referral systems. The importance of the organisational context has become apparent as we try to establish an evaluation project. The model’s section on identifying who has the power, as well as who does the work, may help us to find our way through the complexity of the health care organisations. In our early consultations, members of the community emphasised the need to raise community awareness about the chiropractic service, but insights from the model suggest that arranging more focused meetings with health workers to discuss team working and communication are also important.
Our consultations and experience highlight the existence of a theme that is not identified by the model, which may be described as emancipatory. The verb ‘emancipate’ is defined as ‘set free, especially from legal, social or political restrictions’ [
20]. The normalisation model conceptualises an intervention as becoming embedded through aligning itself with the status quo and current biomedical beliefs, values etc., rather than any suggestion that the intervention could be demanded by patients and introduced in order to change the status quo. Whilst this reflects the body of UK research that May synthesised, it may need amending for use in the context of an Indigenous culture struggling with a lack of culturally sensitive healthcare. For example, a strong sense from the community members was “
the importance of the tactile therapies in healing their people in not only physical ways but healing emotional injuries as well (
the anger in the communities)”. Community and staff members also used participatory action research methods and individually specified aims for the chiropractic service. There was a wide range of individual aims but the one that best sums up the commonest themes is “
For the ACMS to be a recognised place that community can go to get pain relief without medications”. Other common themes were a desire for a holistic approach, for community wellness and empowerment, and for better acceptance and communication of chiropractic. The belief that informing patients about the service would lead to doctors referring to the service because of patient demand was strongly held. As it stands the model suggests this would not work, because both patient and doctor wish to avoid difficult interactions which threaten their relationship. It remains to be seen whether Indigenous structures and community support, and the advocacy of the AHWs, will allow patients to be more assertive in their interactions with doctors. Ongoing discussions with the Indigenous community, plus the results of our mixed method evaluation, may help us to define more clearly whether an emancipatory dimension is an important addition to the normalisation process model in this context.
Our findings accord with other evaluations of integrating chiropractic care into mainstream services. For example the key success factors identified by Kopansky-Giles et al. (2010) were: the importance of champions, laying groundwork, the organisational culture and the choice of practitioners; and the barriers in this inner-city setting were: funding, lack of awareness of the service and perceptions of risk [
21]. The importance of champions and of trust in the ‘right’ practitioners has been confirmed elsewhere [
22] and are issues that continue to be central to our project as we move into the next phase. In terms of the specific aim of embedding chiropractic into marginalised communities, future work will also include comparing our approach with that of Mior and colleagues who recently developed a framework for the integration of chiropractic services into a multidisciplinary practice in Canada [
16]. As the key categories of that framework are communication, practice parameters and service delivery, it would appear that our two approaches are complementary and that further work within the context of health care for First Nation People will further strengthen the link between theory and practice. Aboriginal populations in Australia, New Zealand, Canada and the USA share many commonalities and a number of initiatives have demonstrated that well-resourced, community-controlled and culturally appropriate and accessible programs can, and do, have a positive impact, and result in significant and sustained improvement in the health outcomes of Aboriginal people [
23].
The normalisation process model and theory has been successfully used in other contexts, such as implementing change in primary care for depression [
18], evaluating a self-management training package in primary care [
24], and normalizing a new technology in infertility management [
25]. However, the application of the theory that these papers describe is complex and thus likely to be inaccessible to many non-academic service providers. The model with a revised terminology described in this paper, and the example of its application in a marginalised community, may be of great benefit to others seeking to embed new services into mainstream healthcare. The limitations of our study include the use of a single case study and the emergent nature of our understanding of the theory, which were compounded by the remoteness of the community and our limited resources. However, the utility of our adapted model in the face of these difficulties indicates that it may be applicable in many other poorly resourced settings. The authors of the normalisation process theory, acknowledging the need to translate it to make it useful for non-academic health service providers, have recently developed a simplified web-based version [
26]. In this respect, this paper is part of an important movement to translate the theory from its abstract form to one that can be used to solve problems in everyday settings.
Acknowledgements and funding
We acknowledge with gratitude the on-going support of the Indigenous Elders and Community Advisory Group who provide invaluable guidance for this project and our relationship with the Indigenous community. Of special mention is Mrs Leanne Clay, our on-the-ground Research Assistant who has worked tirelessly to promote the chiropractic service. This project would not be possible without their input. The support, advice and cooperation of the staff of the two clinical facilities are also gratefully acknowledged. We acknowledge and make special thanks to Dr Gay Edgecombe who led the action research and contributed to some consultation meetings. We also thank the School of Health Sciences, RMIT University, the Chiropractors Association of Australia and Hands on Health Australia who have provided on-going support for this project and Dr Fraser Rogerson (RMIT University) for his help in revising the manuscript.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
BP, DV, JvR developed the programme of research, the chiropractic service and the consultation meetings and helped to draft the paper. CP conceived of and drafted the main outline of the paper and participated in designing and consulting on the service evaluation. All authors read and approved the final manuscript.