June 18, 2019
First Nations researchers say influenza vaccination rates among First Nations peoples would be best improved by real and meaningful partnerships where First Nations people are leading all stages of public health initiatives.
In a letter to the Editor (shown below) responding to a 2018 research paper by Borg and colleagues published in the medical journal Vaccine, APPRISE researcher Kristy Crooks and colleagues said vaccine delivery rates would best be improved by First Nations peoples having “a real say about defining the issue/s, suggesting the solutions to be trialled and interpreting results”.
In a reply to this letter, Borg and colleagues, authors of the original article, wrote: “We respect and agree with the recommendations outlined in the letter to make First Nations people central to trial development and implementation.”
Read below the letter to the Editor (Crooks et al. 2019) and the reply (Borg et al 2019) from the authors of the original study.
Letter to the Editor in response to the article by Borg et al
Kristy Crooks, Katrina Clark, Natalie Allan, Paula Taylor, Adrian Miller, Sandra Campbell. Vaccine, 2019-06-06, Volume 37, Issue 26, Pages 3381-3381, https://doi.org/10.1016/j.vaccine.2019.05.021. Copyright © 2019 Elsevier Ltd, https://www.sciencedirect.com/journal/vaccine
As Australian First Nations people, public health practitioners and academics, we would like to thank Borg et al. for the raising the importance of increasing influenza vaccination rates . The coverage of influenza immunisation in Australian First Nations children is close to 50% in the Northern Territory but is very low in most other states, thus this is a topic worthy of research. We would, however, like to offer an additional interpretation of their study results.
Raising immunisation coverage from 4% to 6% is reported in the paper as a statistically significant result. We feel the most important result is that at least 94% of children remained unimmunised.
Whilst the authors acknowledge that the issue requires further research, we would like to offer an alternative perspective on strategies to increase influenza vaccination rates in First Nations communities. For example, instead of focusing on letters and pamphlets for parents and guardians as modes of communication, as described in the article, we suggest that focusing on Cultural Governance is most important. First Nations people must have a real say about defining the issue/s, suggesting the solutions to be trialled and interpreting results.
It is not clear to what degree the study reported in Borg et al. involved First Nations people in study design and governance or the intervention implementation. We strongly advocate exploring models of vaccine delivery that are flexible, family-centred, and characterised by beneficial robust partnerships . We recommend establishing a culturally appropriate governance structure at the outset of work undertaken in this area, whereby First Nations people make a real contribution and participate fully in shared decision-making. If we continue to conduct studies that are not led by First Nations people, then they are likely to yield the same results, perhaps with little to no benefit to the health of First Nations people. We believe First Nations people can be centrally positioned in this type of work, in spaces where there is shared power and empowerment, to ameliorate the health and social impacts of colonisation.
Thus we propose an approach that is informed, developed, led and governed by Australian First Nations peoples . Genuine, meaningful and respectful engagement and action that facilitates active and equal participation is critical in the development, implementation, interpretation of findings, and dissemination of any health program or research .
We would like to acknowledge and thank Patrick Cashman, Ross Andrews, Peter Massey, and David Durrheim for their continued support and being willing to give up space and share power ensuring we as First Nations people have a voice.
 K. Borg, K. Sutton, M. Beasley, et al. Communication-based interventions for increasing influenza vaccination rates among Aboriginal children: A randomised controlled trial.Vaccine, 36 (45) (2018), pp. 6590-6795. https://doi.org/10.1016/j.vaccine.2018.09.020
 S. Thomas, P. Cashman, F. Islam, et al. Tailoring immunisation service delivery in a disadvantaged community in Australia; views of health providers and parents.Vaccine, 36 (19) (2018), pp. 2596-2603. https://doi.org/10.1016/j.vaccine.2018.03.072
 L.M. Jamieson, Y.C. Paradies, S. Eades, et al. Ten principles relevant to health research among Indigenous Australian populations.Med J Aust, 197 (1) (2012), p. 16. https://doi.org/10.5694/mja11.11642
 National health and medical research council (Australia). Values and ethics: Guidelines for ethical conduct in Aboriginal and Torres Strait Islander health research. The Council; 2003.
Reply to letter to the editor in response to the article “Communication-based interventions for increasing influenza vaccination rates among Aboriginal children: A randomised controlled trial”
Kim Borg, Kim Sutton, Megan Beasley, Fraser Tull, Nicholas Faulkner, Justin Halliday, Cameron Knott, Peter Bragge. Vaccine, 2019-06-06, Volume 37, Issue 26, Pages 3382-3382, https://doi.org/10.1016/j.vaccine.2019.05.008. Copyright © 2019 Elsevier Ltd https://www.sciencedirect.com/journal/vaccine
We would like to thank the authors of this letter for taking the time to engage with our paper, “Communication-based interventions for increasing influenza vaccination rates among Aboriginal children: A randomised controlled trial.” Although the study resulted in a modest increase in immunisation rates, we recognise that there remains a substantial challenge to be addressed in optimising immunisation coverage in this population.
We respect and agree with the recommendations outlined in the letter to make First Nations people central to trial development and implementation.
We acknowledge that our engagement with the Aboriginal community in Victoria, while not completely absent, was not best practice. When designing the interventions, we drew upon findings from previous studies and consulted with Aboriginal Victoria and the Victorian Aboriginal Community Controlled Health Organisation (VACCHO) to inform intervention design. In part, this limited engagement was driven by the timing of the trial which only allowed a limited time to put the trial in field in between recognising the need to address low influenza vaccination rates among Aboriginal children and the start of the influenza season in Victoria.
After the completion of the trial, we presented the results at the 6th annual National Health and Medical Research Council (NHMRC) symposium on research translation, co-hosted by the Lowitja Institute  . The symposium had a strong focus on First Nations people’s health. We took the opportunity to incorporate suggestions from the audience regarding the interpretation of our results and in recommending future initiatives.
We also see how such partnerships can enrich interpretation of trial findings and exploration of further avenues of enquiry. In acknowledging these insights, we are aware that our research colleagues in countries such as New Zealand and Canada do their work in the context of treaty arrangements that embed such practices from the onset of research. Whilst Australia does not have a treaty with our First Nations people, we are fortunate that our state, Victoria, is pursuing this ambition  .
At the conclusion of any research project there are lessons from the research findings, and lessons from the way the research was conducted. We again thank the authors of this letter for reinforcing the important lessons we learned from our first trial focussed on a First Nations group.
Declaration of Competing Interest
The authors declared that there is no conflict of interest.