In this study, we engaged health providers and Indigenous women with the aim of integrating their views into the development of a postpartum program. We report four key findings. Firstly, individual and community level programs must occur in parallel with structural changes designed to address food insecurity and adequate facilities to exercise. Secondly, programs need to be community driven and co-designed with participants. Thirdly, programs should be grounded in Indigenous conceptions of health and finally, lifestyle programs were preferred over metformin.
Community lifestyle interventions should occur in parallel with policies at a government level. Like other remote Indigenous communities, community A and B have experienced a recent history of colonisation with enduring effects, including substandard housing, food insecurity, psycho-social stressors and a lack of economic and occupational opportunities (29). Although traditional food practises continue to play an important role within community, colonisation brought rapid lifestyle change with adverse changes in physical activity and nutrition (30, 31). In our study, food insecurity was a key issue repeatedly identified by participants as a barrier to eating well. Gorton et al’s review on interventions to address food insecurity in high-income countries, reports a lack of evidence that community programs alone effectively reduce food insecurity (32). Instead, governmental efforts to improve household incomes and reduce overcrowding, that work alongside community programs would likely go further to reduce food insecurity (32).
There is substantial evidence for the benefits of healthy diet and physical activity in preventing and improving type 2 diabetes and cardiovascular disease (8). However, despite the high rates of these conditions among Indigenous populations, examples of lifestyle programs are rare. Two systematic reviews on physical activity in Indigenous populations in North America (33) and in Australia and New Zealand (34) report both a small number of interventions and a lack of evaluations of these interventions. Hence, it is currently unclear how successful programs are, at increasing activity levels for Indigenous populations, and certainly there is no evidence for programs in the postpartum period.
What is clear, and consistent with our findings, are that many lifestyle initiatives are short-lived, without the sustainability to create lasting impacts for communities (35). Alternatively, programs that are initiated by the community are more likely to have positive health effects (14, 36). A systematic review of nutrition programs for Indigenous Australians report the most important factor determining the success of such programs is community control of development and implementation (14). The Healthy Communities Project was a multi-component strategy that partnered with community leaders to reduce sugary drink consumption in remote communities in Queensland. Engagement from a range of stakeholder groups resulted in changes in increased water sales and decreased sugary drink sales (37). A community driven diabetes prevention program in a Maori rural community in New Zealand had similar positive results, with the investigators attributing its success to community ownership (38). Our research, with participants reporting a desire for programs to be community driven, adds to the body of literature supporting the co-design of lifestyle programs. Co-design is considered best practice in research involving Indigenous peoples, and defined as meaningful end-user engagement in research design with engagement across all stages of the research process, with clear guidelines in New Zealand, Australia and Canada (39–41). We recommend that collaboration occurs between researchers and participants from the onset of the design of a postpartum program.
Connection to and appreciation of the land holds great importance to many Indigenous Australians (42). As reported by Thompson et al, being “on Country” plays an important economic, dietary and cultural role in many communities (42) and we found participants expressed improved physical and mental health when they felt connected to Country and expressed a desire for dietary programs to incorporate traditional food practices. Similarly, in a study among Cree women with a history of GDM, the importance of incorporating traditional elements into a diabetes prevention program was underscored (43). A systematic review on the benefits associated with engagement in Aboriginal Land Management activities (Australia and Canada), reported such engagement to be associated with significant health benefits through improvements in diet, activity, autonomy, and social and spiritual connection to land (44). Like exercise programs, rather than approaching diet through the biomedical model, Indigenous peoples' understandings of food systems and well-being should provide the foundation from which to reset the narrative in relation to diet and health (45).
One’s primary role as a family and community member was evident throughout our interviews. As described in the literature, (35) many of our participants expressed shame if participating in exercise for personal reasons rather than for the benefit of the community or family. Whilst the concept of shame has been variously described, in Indigenous culture it can refer to situations in which a person is singled out, or the centre of attention and the associated concern regarding what others would think (46). Shame is reportedly one of the largest hindrances to young Indigenous women participating in physical activity (47). Hence, individual style programs such as walking groups are unlikely to work in this context. Generally, women in our study were not interested in joining such groups due to (i) the individual nature and associated shame and (ii) the reliance of previous programs on people outside of the community to run them and the transient nature of such people. Alternatively, group sports, that give women a sense of collective identity from being part of a team, are more likely to be effective and could aid in keeping women connected to family and community (48). In addition, women expressed a desire for group sport to be for women only.
Given the known barriers to lifestyle change, we asked participants for their perspective on using metformin to prevent diabetes. Metformin was not the preferred option by most of our participants. There were concerns with adherence given its gastrointestinal side effects and large size and practical considerations around length of treatment. Furthermore, all participants were able to identify clear gaps in lifestyle optimisation and expressed a preference to address these gaps prior to medicalising what many considered to be an environmental and structural issue.
Strengths of this study include the extensive involvement of (i) local Aboriginal Community Workers who were crucial in establishing a culturally safe space and ensuring appropriate interpretation of Indigenous women’s voices and (ii) the guidance of the IRG, who were actively involved throughout the project. There were several limitations. We were unable to return to communities to discuss themes in person with Aboriginal Community Workers due to travel restrictions in the setting of the COVID-19 pandemic. However, to cross-check the interpretation of findings and minimise biases, conversations between AW and the Community Worker were had after each interview and SG analysed all transcripts. There was a smaller number of women recruited from community B compared to community A due to travel restrictions; however, themes were consistent across the two communities and we believe data saturation was achieved to fulfil the study aims.