Globally, Indigenous peoples experience significant health disparities (1). Aboriginal and Torres Strait Islander (hereafter respectfully referred to as “Indigenous”) Australians experience disparities in health status and poor access to/quality of care when compared to non-Indigenous Australians (2, 3). Improving the quality of primary health care provided to Indigenous Australians is one necessary step to redress these health disparities (4). Continuous quality improvement (CQI) methods are key to improving primary health-care service delivery, with an emerging evidence base demonstrating promising results in Indigenous health (5, 6).

Systems and stakeholder capacity to participate in and lead CQI research in Indigenous primary health care is required to generate benefits (7, 8). Yet the processes, skills, knowledge, and system supports necessary to undertake CQI research in this setting have been largely undefined and fragmented. This raises the question of what is an appropriate model of CQI research capacity strengthening (RCS) in Indigenous primary health care that is of value and benefit to Indigenous Australians?

The Centre for Research Excellence in Integrated Quality Improvement for Indigenous primary healthcare services (the Centre) has collaboratively developed a CQI-RCS model. This model draws on capacity strengthening (9) and quality improvement capacity building evidence (10), to theorize strategies to strengthen capacity for CQI research in Indigenous primary health care. Reflecting extant capacities, loci of power, cultural strengths and relationships, the model aims to strengthen existing capacity rather than assume a need to “build” from a zero base (11); as reflected in the Centre’s “all teach, all learn” approach to CQI-RCS. This paper presents the model’s development and four principles to inform approaches to Indigenous health RCS.

Continuous quality improvement refers to “a system of regular reflection and refinement to improve processes and outcomes that will provide quality health care” (12). Through CQI research, primary health-care quality improvement efforts have been accelerated and strengthened at multiple levels and contexts (13). Clinical performance assessment and improvements have been achieved across a range of services (14, 15) and structured health service and systems assessment facilitated to support best practice (16, 17). CQI research continues to play an important role in testing the acceptability of CQI approaches and their impact on Indigenous primary health care (5, 18).

In Australia, CQI methods have attracted significant resourcing and policy focus, including for Indigenous primary health care. The National CQI Framework for Aboriginal and Torres Strait Islander Primary Health Care and the National Aboriginal Community Controlled Health Organisation both prioritise CQI-RCS in the Indigenous community-controlled sector to support co-creation and translation of CQI knowledge (19, 20). The National Health and Medical Research Council funded the Centre for 2015–2019 to improve Indigenous health outcomes by accelerating and strengthening system-wide CQI efforts. The Centre brings together leaders and practitioners of CQI in Indigenous primary health care from community-controlled and government health services, universities, research centers, and policy organizations across Australia (21).

The capacity to perform research is an essential component of a well-functioning public health system (22). A variety of research capacities are required to lead and/or participate in health research aimed at individual, organizational, and systems-level change (23). RCS occurs through research processes and systems, including but going beyond individual training when health equity is the goal (11). Health RCS involves skills- and confidence-building through training, mentorship triads, and apprenticeship-style learning; partnerships and collaborations; dissemination and knowledge translation; empowerment, local governances (ownership) and leadership; as well as infrastructure and resources (24). A literature review by Kahwa and colleagues defined health RCS as:

An ongoing and iterative process of empowering individuals, interdisciplinary teams, networks, institutions and societies to identify health and health-related challenges; to develop, conduct and manage scientifically appropriate and rigorous research to address those challenges in a dynamic and sustainable manner; and to share, apply and mobilize research knowledge generated with the active participation of engaged stakeholders and decision-makers (25).

This definition underscores the need for a systems-orientation and the importance of empowerment and capacity in research production and utilization. The Kahwa definition does not detail specific capacities to be strengthened through RCS. The definition does, however, identify a framework in which RCS occurs within and across five structural levels: individual, team, health services, network and support, and national research infrastructure/bodies (25). Eight integrated dimensions for health RCS design, coordination and evaluation span the five levels (25):

building skills and confidence

The backdrop to Indigenous health RCS is a history of imposed research that generally has not benefited Indigenous Australians, reflecting the exploitative nature of colonization in Australia (7, 26). We acknowledge there are positive examples of Indigenous health research. Yet historically research was about examining and documenting the “exotic other” and conducted to protect non-Indigenous populations from disease (27). More recently, it has often served the priorities of non-Indigenous researchers and perpetuated a deficit-narrative that justifies mainstream intervention in Indigenous people’s lives “for their own good” (28). Such an approach undermines Indigenous control—an important determinant of population health and wellbeing (29)—while overlooking the value and strengths of Indigenous knowledge, experience, and perspectives (30).

Indigenous health RCS is important for self-determination of health research and sustainable outcomes for Indigenous people (31, 32). Research led by Indigenous people and communities provides a means of re-asserting control over country, livelihoods, and knowledge impacted through colonization (33). Indigenous research leadership has been changing the narrative so that Indigenous paradigms, community needs, priorities, and culture are at the center of health research, and designed to deliver benefit to Indigenous peoples (8). Capacity development of all involved in Indigenous health research remains a crucial factor for successfully developing this new research paradigm (8).

One 5-year Indigenous RCS intervention found that keys to success were: an agreement to embrace Indigenous research principles with creation of space for two-way learning between Indigenous and non-Indigenous researchers; recognizing Indigenous ownership, leadership and respect as core to an Indigenous research agenda; and acknowledging “cultural difference challenges” inherent to relationships between Indigenous and non-Indigenous researchers (34). As such, Indigenous health RCS must involve mutual learning (35)—“all teach, all learn”—and a strengths-based approach to Indigenous health research that embraces concepts of Indigenous wellbeing, knowledge and sovereignty (30, 36, 37).

The Centre developed and implemented a dedicated CQI-RCS Program, which intersects with its network and research programs, and seeks to enhance capacities within the Indigenous primary health-care setting to conduct and use CQI research. The Centre’s motto, “all teach, all learn” embodies the value placed upon mutual learning, where CQI-RCS Program users are both learners and teachers. CQI-RCS Program users include Indigenous and non-Indigenous:

research translators: service providers, managers, policy makers, and communities in areas relevant to comprehensive primary health care in Indigenous communities.

The collaborative development of the CQI-RCS model commenced with the appointment of a full-time RCS fellow in 2016, followed by establishment of a RCS Lead Group (Lead Group), development of a values and ethics protocol (Table 1), and construction of a program logic to guide the embedding of the CQI-RCS Program across the Centre’s activities.

Four principles informed the CQI-RCS approach and provide a possible starting point for those seeking to implement RCS models in Indigenous primary healthcare contexts. The principles are discussed in detail below: (1) mutual/two-way learning; (2) Indigenous co-leadership as core; (3) sharing power and facilitating relationships; and (4) resourcing and continuous improvement.

CQI-RCS must occur across multiple domains and levels to enable broader, systems-level engagement in health research at all stages, from research question formation to dissemination of outcomes. Our multi-level, systems view of CQI-RCS is consistent with other RCS models, such as that of Kahwa et al. (25) (described earlier) with integrated dimensions at individual, team, health service, network, and national levels. Our model adds to this by including the requirement that CQI-RCS is contextualized according to Indigenous leadership, knowledge, and aspirations, with principles to guide an approach to CQI-RCS.

As stated earlier, our model draws on generic and quality improvement capacity building evidence. Like quality improvement capacity building (10), knowledge is limited regarding methods to attribute successful elements to RCS interventions (25). The numerous RCS definitions in the literature (23, 60–63) are reported to have adversely affected development of meaningful assessment, monitoring, and evaluation of RCS; so has the context-specific and complex nature of RCS (25). The CQI-RCS principles presented here provide a pathway to address this knowledge gap, through implementation and evaluation in other contexts.

We acknowledge that while program logics have considerable merits, their linear and managerial format can be alienating, lack a systems perspective, and neglect relationships between people and process issues (64, 65). Some program logics include feedback loops to counter the typical linear approaches (66). Like other researchers (67, 68), we consider our program logic (Figure 1) to be an approximation of an anticipated path to be adjusted over time, rather than a replica of reality.

A strength of this CQI-RCS model is its emphasis upon inclusivity of voices and co-leadership, which is reflected in its collaborative development. A traditional, Western approach to research does not convey the model’s espoused principles of power-sharing, and Indigenous and non-Indigenous co-leadership. We are conscious that Indigenous health RCS may have produced unintended consequences of non-Indigenous researchers benefiting (through grants, publications, etc.) at the expense of Indigenous-led research (44, 69). However, these tensions are not reason to discontinue involvement of non-Indigenous researchers; nor do we believe this CQI-RCS work has been at the expense of Indigenous-led research. Rather, non-Indigenous researchers must uphold the struggle for genuine self-determination of Indigenous people and engage with Indigenous people as thinkers, knowers, and experts (30). Our model, with its guiding principles and logic, provides a tool to guide RCS in Indigenous primary health-care contexts, to enable sustained and Indigenous-controlled health research that benefits Indigenous people and communities, framed within a CQI and systems approach.

This paper presents the development of a CQI-RCS model in Indigenous primary health care. The program logic provides a framework for CQI-RCS implementation, monitoring and evaluation of collaboratively determined priorities and outcomes. This is important because there are no existing models of which we are aware that articulate and inform CQI-RCS in Indigenous primary health care in this way. The model also points to the importance of mutual learning, Indigenous co-leadership, power-sharing and sufficient resourcing. The new knowledge generated through developing this model echoes calls of Indigenous Australians seeking research reform that benefits Indigenous peoples (7, 26, 33, 57). The CQI-RCS model presents a possible pathway to enhance capacities to conduct and use CQI research that is valued by and of benefit to Indigenous peoples in the Indigenous primary health-care setting.

Co-Lead: Veronica Matthews, Research Fellow, Wingara Mura Leadership Program Fellow, The University of Sydney, University Centre for Rural Health; Co-Lead: Karen McPhail-Bell, Research Capacity Building Fellow, University of Sydney, University Centre for Rural Health; Kerry Copley, CQI Program Coordinator—Top End, Aboriginal Medical Services Alliance NT (AMSANT); Louise Patel, CQI Program Coordinator—Central Australia and the Barkly, AMSANT; Roxanne Bainbridge, Principal Research Fellow—Indigenous Health, School of Health, Medical and Applied Sciences, CQUniversity; Michelle Redman-MacLaren, Adjunct Academic, Centre for Indigenous Health Equity Research, CQUniversity; Senior Research Fellow, College of Medicine and Dentistry, James Cook University; Deborah Askew, Research Director, Southern Queensland Centre of Excellence in Aboriginal and Torres Strait Islander Primary Health Care (Inala Indigenous Health Service); Shanthi Ramanthan, Post Doctorate Fellow—Health Research Economics, Hunter Medical Research Institute; Nalita Turner, Researcher, Menzies School of Health Research; Ross Bailie, Director, University of Sydney, University Centre for Rural Health—North Coast; CIA the Centre; Jodie Bailie, Research Fellow (Evaluation), University of Sydney, University Centre for Rural Health; Isaac Hill (January–April 2017), Statewide Data and IT Coordinator—CQI Unit, Aboriginal Health Council of SA; Janya McCalman (January–April 2017), Senior Research Fellow, School of Health, Medical and Applied Sciences, CQUniversity.

KM-B conceived, drafted, reviewed, and finalized the manuscript for submission. All authors critically revised and approved this manuscript and, with the Lead Group (named in Acknowledgements), provided co-leadership for the Centre CQI-RCS work that forms this manuscript’s content.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.