Family-centred interventions by primary healthcare services for Indigenous early childhood wellbeing in Australia, Canada, New Zealand and the United States: a systematic scoping review

Background Primary healthcare services in Australia, Canada, New Zealand and the United States have embraced the concept of family-centred care as a promising approach to supporting and caring for the health of young Indigenous children and their families. This scoping review assesses the quality of the evidence base and identifies the published literature on family- centred interventions for Indigenous early childhood wellbeing. Methods Fourteen electronic databases, grey literature sources and the reference lists of Indigenous maternal and child health reviews were searched to identify relevant publications from 2000 to 2015. Studies were included if the intervention was: 1) focussed on Indigenous children aged from conception to 5 years from the abovementioned countries; 2) led by a primary healthcare service; 3) described or evaluated; and 4) scored greater than 50% against a validated scale for family-centredness. The study characteristics were extracted and quality rated. Reported aims, strategies, enablers and outcomes of family-centredcare were identified using grounded theory methods. Results Eighteen studies (reported in 25 publications) were included. Three were randomised controlled studies; most were qualitative and exploratory in design. More than half of the publications were published from 2012 to 2015. The overarching aim of interventions was to promote healthy families. Six key strategies were to: support family behaviours and self- care, increase maternal knowledge, strengthen links with the clinic, build the Indigenous workforce, promote cultural/ community connectedness and advocate for social determinants of health. Four enablers were: competent and compassionate program deliverers, flexibility of access, continuity and integration of healthcare, and culturally supportive care. Health outcomes were reported for Indigenous children (nutritional status; emotional/behavioural; and prevention of injury and illness); parents/caregivers (depression and substance abuse; and parenting knowledge, confidence and skills); health services (satisfaction; access, utilization and cost) and community/cultural revitalisation. Discussion and conclusion The evidence for family-centred interventions is in the early stages of development, but suggests promise for generating diverse healthcare outcomes for Indigenous children and their parents/caregivers, as well as satisfaction with and utilisation of healthcare, and community/cultural revitalisation. Further research pertaining to the role of fathers in family-centred care, and the effects and costs of interventions is needed.


Background
Primary healthcare services have embraced the concept of family-centred models of care as one approach to improve health and preventive services for Indigenous children [1][2][3]. Family-centred approaches differ from traditional maternal and child healthcare which focus on the management of individual women's pregnancies and infants' health and development at healthcare clinics. Instead, family-centred care approaches provide support and care for the whole family, their lives and wellbeing concerns, often at the family's home.
This scoping review was conducted to inform the development for a Cochrane review protocol [3] by systematically searching, selecting and synthesizing existing knowledge to map key concepts, types of evidence, and gaps in research about family-centred healthcare [4]. As suggested by Dijkers [5], assessments of the quality of the primary studies are included to provide confidence that the implications of the review for policy, practice or patients are based on high quality research. The research question was: What is thecurrent evidence base for the impact of family-centred interventions on Indigenous earlychildhood health? Both the Cochrane and this scoping review were contracted by a Queensland regional Indigenous community controlled health service, Apunipima Cape York Health Council, to inform the implementation of their family-centred Baby One Program (Bainbridge R, McCalman J, Campbell C, Redman-MacLaren M, Vine K, Canuto K, Sewter J, MacDonald M: Growing a relational and responsive family health promotion program: A grounded theory evaluation of the Baby One Program, inpreparation).
In mainstream populations, many health care providers now recognise family-centred care and the related concept of patient-centred care as integral to patient health, satisfaction, and health care quality, and consider them to be the standard of child health care [6]. For example, the US Healthy People 2020 plan for children recommends that children with special health care needs should receive care in a "family-centred, comprehensive, coordinated system" [7]. There is evidence from mainstream settings that family-centred interventions have resulted in decreased depression rates and burden in carers, improved quality of life for the entire family and satisfaction with care, as well as greater health service effectiveness and efficiency with reduced cost [8].
The need for improved child healthcare for Indigenous populations is evidenced by persistent disparities in child health equity in Australia, Canada, New Zealand and the United States. Mortality rates are higher in the four countries for all Indigenous infants except Native Hawaiians; there are generally fewer children born with normal birthweights (between 2500 and 4500 g); and childhood obesity rates are considerably higher for Indigenous than the general populations in each of these countries [1]. These disparities reflect the shared legacy of the impacts of colonisation in these countries; whereby exclusionary social policies have to varying degrees disrupted family relations, continuity and functioning [9].
Many Indigenous families deal with ongoing stressors, which can manifest inpsychological distress, grief, smoking and alcohol and drug misuse, mental illnesses, and/or violence; and thus their ability to nurture children [9]. In turn, families can experience issues such as lack of food security, child neglect, and the removal of children [10]. However, Indigenous families also commonly experience strengths, such as strong bonding capital associated with their inclusion of members of their extended families, and the influence of traditional cultural norms on child rearing practices [9]. These strengths provide opportunity upon which engagement in health promoting family-centred approaches with services can be built to support improvements both to family lifestyle factors but also on the upstream social determinants of Indigenous childrens' health and wellbeing [9].
Primary health care services in Indigenous communities, which are increasingly managed and delivered by Indigenous community controlled health services, have taken opportunities to develop and implement family-centred interventions to improve Indigenous child health. By ensuring that care is planned and implemented around the whole family, family-centred interventions have the potential to recognise and support Indigenous family functioning, that is, their communication, maintenance of relationships in healthy ways, decision making and problem solving [11]. Health services can also advocate to address system barriers to improved family health, such as for education, training, employment, and to child protection agencies.
There are differing definitions for family-centred healthcare, and consequently various approaches. Nixon [12] defined the delivery of family-centred care by health services as "a way of caring for children and their families within health services which ensures that care is planned around the whole family, not just the individual child/person, and in which all the family members are recognised as care recipients". Griew, Tilton, and Stewart [13] proposed a broader two-part definition of Indigenous family-centred healthcare as: 1) movingbeyond providing care to the individual patient, to seeing them as being embedded in a family and providing services on that basis; and 2) taking a life course approach, which, without neglecting adult health, focused specific attention on establishing early life resilience and advantages through an emphasis on child development. This paper reviews the state and quality of the evidence for family-centred healthcare delivered through primaryhealthcare services for Indigenous children (from conception to 5 years). The review objectives were: 1) Outline the extent of the current evidence base for family-centred interventions by primary healthcare services for Indigenous Australian, Canadian, New Zealander or United States early childhood wellbeing; 2) Examine the conditions which enable primary healthcare services to implement family centred interventions, and the strategies they use to do so; 3) Describe the outcomes of family-centred interventions for Indigenous early childhood wellbeing.

Inclusion/Exclusion criteria
Studies were included in this scoping review only if they were published in English from 1 January 2000 to 31 December 2015 inclusive. The start date of the review was taken from 2000 when the US formally recognised patient-centred care as a healthcare standard [14]. Publications were also included only if the study met each of the following four criteria: 1. Participants were Indigenous Australian, Canadian, New Zealander or United States children aged from conception to five years who received family-centred care. A child was considered to be Indigenous if they were identified by the family as Indigenous (one parent may have been non-Indigenous); 'Indigenous' was defined using the United Nations definition of self-identification and acceptance by the community as a member [2]. 2. Evaluated or described a family centred intervention or theorised a family centred healthcare model. We used Nixon's [12] definition of family-centred healthcare and included: a) environmental interventions that maximise parental involvement and enhance child health or wellbeing; b) communication interventions that include parents/ caregivers in collaborative care pathways, and/or reorganisation of health care to provide continuity of carers; c) educational interventions for parents/ caregivers or staff; d) counselling interventions such as brief interventions, home visiting and other approaches; and/or e) family support interventions such as flexible charging schemes for poor families, referrals to other community services, parent-to-parent support [15]. We included pregnancy care models only if the intervention continued beyond the standard postpartum period of six weeks to at least three months. 3. Intervention scored greater than 26/52 points (50%) against a validated scale for family-centredness [15,16]. The scale incorporated 13 criteria, clustered under three concepts: 1) family as a constant (family as a constant in child's life, recognising family strengths, collaboration between parents/caregivers and professionals, needs-based family support, flexible provision of health care, sharing information with families); 2) culturally responsive (culturally competent health care, respecting family diversity, providing financial support); 3) supporting family individuality & need for different types of family support (respecting family coping methods, providing emotional support, family-to-family support, attending to the developmental needs of children and families). Each criteria were scored from zero (no evidence that the author(s) addressed, endorsed, or advocated adoption of adherence to the elements of family centred care either implicitly or explicitly) to four (numerous instances of explicit evidence that the author(s) advancedadoption or support of the elements of family-centred care). 4. Intervention was led by a primary healthcare service, defined broadly as healthcare providers involved in providing primary healthcare for Indigenous children.

Search strategy
In consultation with an expert librarian (KK), a four-step search strategy was implemented.
Step Step three comprised a search of the reference lists of Indigenous maternal and child health systematic reviews. In step four, the authors of this study also drew on their knowledge of family-centred interventions.

Identification, screening and inclusion of publications
The combined searches were imported into a bibliographic citation management software, EndNote X7 with duplicates removed. Titles and abstracts of the remaining publication titles and abstracts were screened by one author (MH). A second author (JM) retrieved and screened titles and abstracts of the remaining publications; those which did not meet inclusion criteria were excluded. The full texts of the remaining publications were retrieved and screened by blinded reviewers (RB, SC, CC, MH, JM, AR) and independent reviewers from Apunipima Cape York Health Council and Centre for Research Excellence for Improving Health Services for Aboriginal and Torres Strait Islander Children (ISAC) (KE, RM, MRM, LS, NS, KT, MW). Inconsistencies in reviewer assessments were resolved by consensus.

Data extraction & analysis
The publications were grouped together under the name for the study. Data were extracted from the full texts for publication authorship, publication year, study design, year/s of data collection and outcome assessment interval, study setting, population and sample size. The quality of included quantitative studies was assessed by blinded reviewers (SC and CC) using the Effective Public Health Practice Project quality assessment tool [17]. Qualitative studies were assessed by blinded reviewers (MH and JM) using the Critical Appraisal Skills Programme quality assessment tool [18]. The costing study was assessed by a health economist (IK) and author (JM) using the Joanna Briggs Institute critical appraisal checklist for economic evaluations. The publications were then imported into NVIVO software and coded (by MH). Grounded theory methods were used to map the strategies and outcomes of family-centred interventions, as well as the contexts and conditions under which they develop [19]. Grounded theory methods are well suited to conducting exploratory scoping reviews, especially in areas like family-centred interventions for Indigenous early childhood health, which is complex and has not been reviewed comprehensively before [19].
We started by coding the studies (seven publications) with the strongest study designs; then continued to code and compare the concepts in the remaining studies [19]. As we progressively coded and compared the papers, we found common or similar groups of concepts that were then recoded as higher order categories [19]. For example, across diverse studies, we identified strategies of providing subsidised fruit and vegetables; providing daily hot nutritious lunches, food coupons and hampers and nutritional supplements. We coded this concept as "augmenting diet". As more papers were coded, similar concepts were identified, such as providing oral health products; and providing safe sleeping baskets. Consequently, we regrouped and re-categorised the earlier code as "value-adding to health through products". Axial coding was then used to sort which of the categories represented the aim, contexts, conditions, strategies and outcomes of the family-centred interventions and to identify the interrelations between these [20]. Through axial coding, for example, "value-adding to health through products" became part of a core strategy titled "supporting family behaviours and self-care". These analytic coding steps did not occur in a lineal order as described here, but were performed interactively, revisiting and refining concepts and categories as new insights occurred [19].

Results
A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart is presented at Fig. 1 [21]. The process of identification, screening and inclusion of publications resulted in 18 included studies (25 publications). One study of the US Family Spirit intervention was reported in five publications [22][23][24][25][26]; the Australian Baby Basket program in three publications [27][28][29], the Australian Triple P parenting study intwo publications [30,31]; and the remaining studies had one publication each.
Twelve/18 studies reported more than one study population. The majority of studies targeted expectant women or new mothers. In order of frequency, other client groups were: Indigenous children, parents/caregivers and other family members and other community members and stakeholders. Program deliverers, in order of frequency, were: Indigenous health paraprofessionals/ workers, senior/Elder women who provided education or support, other health practitioners, senior/Elder men, and partnerships withresearchers. This diversity was related to the inclusivity of many family-centred approaches and the varied modes of their delivery.

Study design
There were three/18 randomised controlled studies (17%), one controlled before and after study (5%) and one mixed method evaluation (5%) to test the impact of familycentred interventions on the quality and effectiveness of care. However, the remaining 13/18 studies (72%) were non-comparison studies, including three uncontrolled before and after studies, seven exploratory qualitative studies two program descriptions and a protocol for a longitudinal study (Fig. 2).

Study quality
Only one/18 studies was rated of strong quality [22][23][24][25][26] ( Table 1). This study randomised 322 participants to the US Family Spirit intervention or optimised standard care, and evaluated outcomes at different time points using validated measurement tools. The other assessable studies were of moderate (7/18) moderate/weak (1/18), or weak (6/18) quality, with lack of consistently strong methodology across the majority of assessed criteria. The quality of two program descriptions and one study protocol were not assessed.

Key elements of family-centred interventions
The aims, strategies, conditions and outcomes of familycentred care reported in each study are summarised in Table 2, where ✓ denotes evidence that the author(s) advanced adoption or support of the element of familycentred care,~denotes an implicit or inferred reference consistent with the intent of that element; and X denotes no evidence for that element of family-centred care.

Aim of family-centred interventions
The aim of study interventions was to promote healthy families; that is, to enable families to increase control over and to improve their health. In 14/18 studies (78%), this aim was explicitly reported , and in the other four, it was inferred ( Table 2). Examples of an explicit aim were to assess the effectiveness and cultural appropriateness of the Triple P parenting program [31]; and to evaluate the impact of a weekly subsidised box of fruit and vegetables [35]. Examples of an inferred aim were to determine family satisfaction with a family-centred service [43,44] and to explore the views of service providers about how family-centred services work [45].

Strategies of family-centred interventions
Six key strategies were identified: supporting family behaviours and self-care, increasing maternal knowledge, linking with the clinic, building the Indigenous workforce, promoting cultural/ community connectedness and advocating for social determinants of health (Table 2). Intervention components varied, with many having multiple strategies.

Supporting healthy family behaviours and self-care
Fourteen studies (78%) explicitly described or evaluated the provision of mentoring, counselling, advocacy and  products to support healthy family behaviours and selfcare [28-34, 41-44, 46]. Mentoring by Indigenous Elders and/or health professionals was provided to encourage reduced or no alcohol use and smoking in pregnancy [28,29,37,38,42,43]; improve nutrition in pregnancy [28,29,35,37,42,44]; safe sleeping [28,29,32]; early childhood healthy eating and exercise routines to reduce obesity [28,29,39]; and care for and learning by disabled children [40]. As well, parents/caregivers were mentored to care for themselves [43] and reward themselves for meeting goals [36]. Counselling or brief interventions were provided to enhance nutrition and reduce alcohol and drug use [28,29,42]. Advocacy was also reported, for example to assist with housing, welfare and legal issues [28,29,42] and for improved services and new models of healthcare [38]. Products, such as food and nutritional supplements, were provided to support women during pregnancy. For example, the Australian Baby Basket program provided antenatal, perinatal and postnatal baskets to Cape York women, which included a baby bed, educational books and clothing, nappies and other items for the baby and mother [29]. The Canadian Sheway program provided daily hot nutritious lunches, food coupons, food bank hampers and nutritional supplements for pregnant women struggling with substance abuse and addictions [42]. Products were also provided for new born infants, such as formula, nappies, clothing, and equipment such as sleeping baskets. Examples included the New Zealand Wahakura, a flax bassinet which was provided to promote safe sleeping for Maori infants [29], the Canadian Sheway program's provision of items for newborn infants [42], and an Australian Aboriginal Medical Service's provision of a weekly box of subsidised fruit and vegetables linked to preventative health services and nutrition promotion [35].

Building the Indigenous workforce
Fourteen studies (78%) reported employment, training and supervision of an Indigenous workforce as a strategy [22-26, 28, 29, 33-46]. For example, two newly graduated Aboriginal midwives were mentored through an urban Australian community midwifery service [40].
The Native American educators of the Family Spirit intervention were required to complete 500 h of training in home-visiting methods and curricular content, had to demonstrate competency in the form of written and oral examinations, and received daily on-site supervision and weekly cross-site conference calls [22][23][24][25][26]. Similarly, an Australian nurse home-visiting intervention provided extensive training for Aboriginal staff instrength-based approaches to attachment theory, child development and socio-emotional issues facing families [28,29,46].    Promoting cultural/Community connectedness Five studies (28%) explicitly promoted cultural, spiritual or community connectedness as a strategy [32,34,37,41,42]. For example, new Maori parents were encouraged to use a safe sleeping device made from native flax, a material which had traditionally been used for weaving and was considered to have sacred and healing qualities [32]. Aboriginal Australian pregnant women were encouraged to make greater use of bush foods [37] and to become more engaged with local community events [41]. Canadian studies described early childhood care and development programs as a 'hub' for meeting a range of service and social support needs of community members [34] and encouraged pregnant women to identify a network of people whom they could call upon for support [42].

Advocating for social determinants of health
Three studies (17%) described advocacy to improve aspects of the social and/or economic determinants of health [34,38,42]. Studies considered family-centred care to be a 'hook' for mobilising community involvement in supporting young children and families [34], advocated to restrict the sale of full-strength alcohol [38], and provided advocacy and support for child access and custody, other legal issues and housing [42].

Enablers of family-centred interventions
The four enablers of family-centred interventions were competent and compassionate program deliverers, flexibility of access, continuity and integration of care, and culturally supportive care (Table 2).

Competent and compassionate program deliverers
Eleven studies (61%) cited the importance of having competent and compassionate staff as an enabler of familycentred care [22-26, 28-31, 37, 40-44, 46]. For example, Arney et al. [46] found that families' views about the program could not be separated from their appreciation of the qualities and abilities of the staff. Barlow et al. [22][23][24] required staff to have the ability to show compassion, be non-judgmental and have inter-personal skills.
Other publications emphasised the need for cultural sensitivity training to promote the interaction of practitioners with clients in ways that respected their cultural orientations and living situations [26,30,31]. Seven publications referred to the cultural competence of Indigenous program deliverers who could accommodate different languages, family and cultural issues [22-24, 28, 29, 37, 41, 42]. Homer et al. [40] however, found that it was the trusting relationship between provider and client that was important; this was not necessarily with an Aboriginal provider. Applequist & Bailey [43] found that 96% clients indicated no preference regarding the ethnic background of their service provider.

Flexibility of access
Another hallmark of family-centred care interventions was the flexibility of access provided to health education and care. All 18 of the included studies (100%) reported flexibility of access, including the provision of homebased care, e.g. [22-26, 28, 29, 31], choice of training location, e.g. [30,31], or less commonly, the provision of transport or transport vouchers to and from services [40,42]. Service providers considered it important to provide flexible access as an enabler of engagement, particularly to families without means of transport.

Continuity and integration of healthcare
Another enabler, reported in 12/18 studies (67%), was the provision of healthcare continuity and integration by linking women across antenatal, birthing and postnatal services and providing integrated wrap-around care [22-26, 33-36, 40-46]. For example, Homer et al. [40] described a healthcare model whereby women were offered continuity of midwifery care during pregnancy, labour and birth; and referral to child health services postnatally after discharge.
Community agencies, health professionals, social workers, life support counsellors, and community Elders collaborated to provide integrated, wrap-around care for families [41,44,46]. Intercultural collaboration across Indigenous and mainstream health services was also considered important [44][45][46]. Leadership was considered an essential component of effective partnerships with other services, families and the community as it enhanced workplace ethos and created an environment where collaboration was supported [45].

Outcomes
Intervention outcomes were reported in the 15/18 evaluation studies (83%) [22-26, 28, 29, 31-34, 37, 39, 40, 42-46] for Indigenous children, parents/caregivers, health services, and broader community/culture ( Table 2). For Indigenous children, reported outcomes included improved nutritional status, emotional and behavioural and preventive health. For parents/caregivers of Indigenous children, studies reported reduced parental/caregiver depression and substance abuse, and improved parenting/ caregiving knowledge, confidence and skills. For health services, reported outcomes included client satisfaction and improved service utilisation and cost of delivery. Community/cultural revitalisation was also reported. Two studies that described programs [38,41] and one study protocol [36] did not report outcomes.

Child health outcomes
Children's nutritional status Seven/15 studies (47%) reported improvements in children's nutritional status including changes in weight (overweight and underweight), growth and/or nutritional markers such as increased haemoglobin levels [28,29,33,35,37,39,42,44]. Improved birth weights were reported following advice in relation to nutrition, alcohol and smoking during pregnancy, and utilisation of adequate and timely medical help [33,37,42]. Increased breast feeding was reported in a self-report survey following an Aboriginal Prenatal Wellness Program [44]. A reduced incidence of faltering growth was reported in an evaluation of the Australian Baby Basket program [28] and a small but significant increase in mean haemoglobin levels of children was found in a similar Australian study following the provision of a weekly box of subsidised fruit and vegetables linked to preventative health services and nutrition promotion [35]. Finally, decreased weight gain in children in the obesity prevention group of a US randomised controlled trial was found following an obesity prevention intervention with mothers of preschool Native-American children [39].

Preventing childhood injury and illness
Five/15 studies (33%) reported outcomes related to the prevention of childhood injury and illness [22-26, 32, 34, 35]. Improvements were found in attitudes toward, or actual home safety [22,23,32,35]. For example, the US Family Spirit intervention resulted in an increased awareness of home safety issues in teen mothers [22,23,26]. The New Zealand Wahakura, a woven flax bassinet delivered with safe sleep messages, improved parental reassurance and confidence while providing the infant with a safe place to sleep in the parental bed [32]. The Canadian Sheway program resulted in housing improvement and lower rates of child apprehension by the Ministry of Children and Family development [42]. Studies also reported up to date immunisations [34,42], screening for children's vision, hearing, and speech [34], and a significant decrease in prescribed oral antibiotics [35].
Parent/carer outcomes Parent/Carer's depression and substance misuse Six/15 studies (40%) reported reductions in parental/ carer depression and/or substance misuse [22-24, 26, 28, 29, 32, 40, 42, 44]. For example, American Indian teen mothers had fewer externalising problems and depressive symptoms after participation in the Family Spirit intervention [22,23]. Similarly, Poole [42] reported decreased substance misuse by pregnant women who participated in the Canadian Sheway program. Also reported were reductions in maternal smoking [32,40,42,44] and use of marijuana and other illegal drugs [23,42]. The Australian Baby Basket program was associated with a decrease in women who consumed alcohol during pregnancy over time. All women who consumed alcohol during pregnancy in 2013 were provided a brief intervention [28].

Parenting/Caregiving knowledge, confidence and skills
Eight/15 studies (53%) reported improvements in parenting/caregiving knowledge, confidence and skills [22-24, 26, 28, 29, 31, 32, 39, 43, 46]. For example, improved parenting knowledge and locus of control were found in Native American teen mothers following the US Family Spirit intervention [22][23][24]26]. Similarly, an Australian nurse-delivered home visiting program resulted in an improved sense of confidence in parenting [46]. Turner et al. [31] and Munns [41] found behavioural and attitudinal changes to parenting including a significant decrease in reliance on some dysfunctional parenting skills. The other five publications that explicitly aimed to enhance parental skills and practices were protocols or program descriptions and did not report outcomes.

Healthcare access, utilisation and cost
Seven/15 studies (47%) reported improved health access or utilisation as an outcome of family-centred care [24, 27-29, 31, 33, 35, 40, 44, 45]. Culturally appropriate services were seen to promote more time for consultations and more opportunity for follow-up than would normally occur in an outpatient setting [28,44,45]. Also reported were earlier and increased utilisation of ante-natal care services [28,33,40] and a breakdown of some of the obstacles Indigenous families faced in accessing mainstream services [31]. A reduction in visits to health services for illness, hospital emergency department attendances and oral antibiotic prescriptions was also found [35]. The Australian Baby Basket program evaluation reported that the cost per Baby Basket participant of about $874 appeared to be a modest investment to provide babies with a better start in life [27].

Community/cultural revitalization
Finally, five/15 studies (33%) reported community or cultural revitalisation as a result of implementing a family-centred intervention [22-24, 26, 32, 34, 35, 37]. The cultural and spiritual value of interventions was considered to be an outcome in its own right; for example, the Wahakura woven flax bassinet had cultural and spiritual value as well as promoting safe sleeping practices [32]. Centre-based interventions also became a focal hub for mobilising community involvement in supporting young children and families and encouraging social cohesion [34], as well as a basis to advocate for improved models of healthcare that offered cultural safety for community members [34,38]. The employment of Indigenous para-professionals was also considered to have the potential to break multigenerational cycles of behavioural health disparities for Indigenous communities [22,23,26,35,37].

Limitations
Although a rigorous and thorough search strategy was used, it is possible that this scoping review did not locate all relevant studies. There was high level of agreement between blinded coders, and consensus on all included studies, but it is also possible that relevant intervention descriptions or evaluations may have been misclassified. Since evaluations with statistically significant findings are more likely to be published, it is possible that the published evaluations reviewed overestimate the true effectiveness of family-centred interventions in health care for Indigenous peoples [47]. this area is of concern given the tendency identified by Popay et al. [51] for policies and programs to lifestyle drift; that is, to recognise the importance of the structural/ political determinants of health inequalities but to respond with action largely on behavioural lifestyle foci.
Another key gap identified in the reporting of intervention strategies pertained to the role of fathers in family-centred care. Ball [52] cited mother-centrism in parenting practices and child welfare services as barriers to positive involvement of Indigenous fathers with their children's health and wellbeing, yet none of the included studies explicitly considered the role of fathers. Further evaluation of the role of fathers in family-centred care interventions is needed through effective partnerships between primary healthcare services and research agencies to evaluate family-centred interventions as they roll out, thus minimising evaluation costs and optimising the use of locally available resources.
Only one study provided evidence of the costs of providing family-centred care to Indigenous families [27], and suggested that costs were offset by potential benefits. The paucity of economic evaluations was an identified gap in the scoping review. Another study of an intervention where senior Aboriginal women provided cultural support to pregnant women from remote Australian communities during labour, which was excluded from the review because it did not continue past one month post-partum, also found that the intervention was likely to be cost effective [53]. The finding suggests the potential for such interventions to be cost effective, but further such evaluations are needed.
A crucial issue in translating the results of this scoping review into policy or practice to inform interventions for improved Indigenous family health is that while the scoping study mapped the research and found 18 studies, these were generally of moderate to weak quality. This scoping review was conducted to produce a broad map of the evidence and to inform the scope and research objective of a Cochrane review protocol [3]. The Cochrane review will provide an independent and rigorous investigation, updated regularly to incorporate new research, of the best available evidence for the effects of family-centred interventions for children and their families. The Cochrane review will ensure that primary healthcare services can base their decisions about optimal interventions for the improvement of families' health on current and reliable evidence.

Conclusion
Family-centred interventions produced outcomes of improving Indigenous early childhood wellbeing, and the health of parents/ caregivers, as well as consumer satisfaction and improved access to mainstream services. The 18 studies evaluated or described the required conditions for implementing family-centred care to be the availability of competent and compassionate program deliverers, flexibility of access, continuity and integration of healthcare and culturally supportive care. Strategies were diverse and included supporting family behaviours and self-care, increasing maternal knowledge, strengthening links with the clinic, building the Indigenous workforce, promoting cultural or community connectedness and advocating for the social determinants of health. However, the evidence base for family-centred interventions by primary healthcare services is in an early stage of development, with few impact evaluation studies available. As well, there was little explanation in the available studies of how families engaged with and were positioned within family-centred interventions, whether or how interventions were able to impact the social determinants of families' health, the role of fathers in family-centred care and the costs of providing familycentred care. This scoping review informs the development of a Cochrane review protocol, which will provide regular updates of the available evidence as it develops.
Abbreviations ISAC: Centre for Research Excellence for Improving Health Services for Aboriginal and Torres Strait Islander Children; PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses