In Australia and other countries, diabetes and obesity are on an upward trend, significantly increasing the burden of disease, and thus is a major global challenge for the public health system (Arredondo, 2013). Caspersen, Thomas, Boseman, Beckles and Albright (2012) points out that diabetes and its comorbidities, especially among adults, account for much of the economic burden of their disease, and this economic burden exerts additional demand on the healthcare system (Arredondo, 2013). It has also been pointed that even though diabetes can be mostly prevented through preventative measures, potentially with the help of health promotion projects, it continues being a common, fast-growing serious and costly health issue (Narayan, Gregg, Fagot-Campagna, Engelgau & Vinicor, 2000). Therefore, disease prevention is an integral component of health promotion strategies addressing this issue. Several studies have shown that lifestyle modification strategies involving healthy diet and physical exercise (along with the administration of the drug Metformin in some cases) can help fight and control diabetes by reducingits incidence risk or/and its complications (Ramachandran , Snehalata, Mary, Mukesh, Bhaskar & Vijay, 2006; Tuomilehto, Lindström, Eriksson, Hämäläinen & Ilanne-Parikka, 2001; Lindström, Peltonen, Eriksson, Ilanne-Parikka, Aunola & Keinänen-Kiukaanniemi, 2013; Dunkley, Bodicoat, Greaves, Russell, Yates, Davies & Khunti, 2014). The current health promotion proposal is an attemptto identify the most effective method of promoting a healthy lifestyle by encouraging positive lifestyle modifications, which can be implemented in a small Indigenous Australian community setting (Colagiuri, Vita, Cardona-Morrell, Singh, Farrell & Milat, 2010).
Considering how lifestyle can increase risk of diabetes and that lifestyle modification can reduce it, it becomes pertinent to integrate lifestyle modification advices in health promotion. Since physical activity and excercise can have beneficial role in the reduction of the burden of disease posed by diabetes, the health promotion will aim to educate the local community to these advantages, and support lifestyle modification
Studies by the Australian Institute of Health and Welfare shows that between 2011 and 2013, indigenous Australian adults (compared to Non Indigenous Australian adults) being 2.6 times more prone to smoke daily, 1.2 times more likely to develop obesity and high blood pressure. The risk of diabetes, cardiovascular disease . Risk of diabetes was found to be 27% more prevalent, with highest risk to adult’s over 65 years (at 60% risk). Similarly, mortality rates among these communities werefound to be higher at younger ages, and rises with the remoteness of the communities, as well as more frequent co morbidities associated with cardiovascular diseases (aihw.gov.au, 2018).
Behavioural risks that increase the prevalence of diabetes, obesity and cardiovascular diseases and hypertension include: smoking tobacco, sedentary lifestyle, alcohol consumption, inadequate consumption of vegetables (aihw.gov.au, 2018).
The study is based on the statistics that shows higher prevalence of lifestyle risks like sedentary behaviour, smoking and alcohol consumption, as well as risks for obesity, diabetes, hypertension and cardiovascular diseases among indigenous Australians, compared to non-indigenous Australians. Furthermore, the higher prevalence health risks are also related to the remoteness of the communities of indigenous Australians (see Appendix A). This highlights the necessity of addressing these health concerns among the native Australian communities.
The method and design will be based on the Sydney Diabetes Prevention Program (SDPP), involving 500 participants between the ages of 50-65 years, all who have been identified at high risk of developing diabetes, from the Tjuntjunjtarra Community, northeast of Kalgoorlie in Western Australia. Screening and subsequent recruitment of the participants to the program will be done within the primary care setup (a local health clinic) and will receive a community-based intervention for lifestyle modifications. This intervention will have 2 components. An initial session conducted one on one, and then a group session consisting of three participants per group. The intervention will aim towards behavioural changes and will have four distinct objectives: 1) Reduction of weight by 5%. 2) Physical exercise of at least 30 minutes per day. 3) Limiting dietary intake of saturated fat to less than 10% and unsaturated fat to less than 30%, and 4) Maintain a minimum intake of dietary fibre at 15g per 1000 kcal consumed. The intervention will be followed by progress review for three months, providing continued lifestyle advice for a year. At the end of each year, the efficiency and cost-effectiveness of the program will be analysed. The analysis will be based on primary outcomes,such as change in weight, diet-habit and physical activity status, and secondary outcomes, such as circumference of weight (abdominal girth), fasting blood glucose levels, blood pressure, lipid profile, quality of life, psychological state and usage/utilization of medication/healthcare services. The selected intervention is based on the interventions used for Sydney Diabetes Prevention Program (SDPP) which studied the feasibility and effective methods in the delivery of interventions to supportand sustain behavioural modifications (Colagiuri, 2010).
Conclusion:
This study can help to decide the feasibility, reach and efficiency of the Health Promotion Model within a small Indigenous Australian community (Tjuntjunjtarra Community, northeast of Kalgoorlie), provided via Primary Healthcare centre located in the community. If the model proves to be effective in reduction of diabetes in the community, it can be further utilized in a wider community setup.
Diabetes has a very high economic burden, entailing a global expenditure of 673 billion US dollars as at 2015, and is expected to rise to above800 billion by 2040 (.diabetesaustralia.com.au, 2015). The number of morbidities due to diabetes and its co-morbidities have accounted for 3.7 million deaths in 2013 globally. Zimmet, Magliano, HermanandShaw,(2014), pointed that the risk of diabetes is the highest among indigenous and economically disadvantaged groups. This is especially more significant in the case of the indigenous Australians, like the Aboriginal and Torres Strait Islanders. In 2015, the Abs.gov.au, (2015) showed a three times risk of developing diabetes among indigenous Australian adults, and eight times among the children and six times the risk of fatalities from diabetes and related complications compared to the non-indigenous counterparts. The details of the statistics have been discussed in the essay portion.
Considering the sharp rise in the incidence of diabetes and its risk factors (like sedentary behaviours, obesity and unhealthy food choices), the consequences of the disease is both very expensive and severe, and therefore very difficult to treat (Hamilton, Hamilton & Zderic, 2014; Garg, Maurer, Reed&Selagamsetty, 2014; Everard & Cani, 2013; Malhotra, Noakes & Phinney, 2015). Hence, a preventative measure can be very effective in loweringthe probability of developing Diabetes, since it encourages an overall healthier lifestyle (thus avoiding other lifestyle-related diseases as well) (Dunkley et al., 2014).
Different studies have shown that interventions for lifestyle modification aimed at improving the diet, amount of daily physical exercise and weight reduction among individuals at high risk of developing diabetes can be very effective for delaying or even preventing the onset of diabetes (Colagiuri et al., 2010). Studies in the US and Finland showed a reduction of diabetes by 58% through lifestyle change, while a reduction in 40% of Type 2 Diabetes was observed by the Chinese Da Qing Study (Tuomilehto, Lindström, Eriksson, Valle, Hämäläinen&Ilanne-Parikka, 2001; Diabetes Prevention Program Research Group, 2002; Pan, Li, Hu, Wang, Yang, An & Jiang., 1997). Furthermore, it was also foundthat these preventative strategies had a long-term effect, by keeping diabetes incidents under control for more than 10 years, thereby continuing the benefits of the strategies (Lindström et al., 2013; Li, Zhang, Wang, An, Gong, Gregg &Engelgau, 2014). Similar studies were done in India and Japan also provided similar benefits, which shows that preventative measures can also be used for the public (Kosaka, Noda &Kuzuya, 2005; Ramachandran et al., 2006).
Effective preventative programs for diabetes need to focus on theoretically based approaches for behavioural modification as a part of the lifestyle modification approach. The behavioural modification further needs to emphasize on the encouragement of changes in diet and an increase in the amount of physical activity, among the high-risk individuals, and components like an initial status check, setting up individualized goals, one to one counselling sessions, continued support, regular assessment and feedback, and ongoing evaluation of the effects of the preventative strategies used. Community-based programs that are based in small communities have shown significant success in implementing lifestyle interventionsto reduce diabetes incidence and its risk factors; as seen in the case of ‘The Greater Green Triangle Diabetes Prevention Project’ in Australia, and ‘The Good Ageing in Lahiti Region Lifestyle Implementation Trial’ in Finland (Kilkkinen, Heistaro, Laatikainen, Janus, Chapman, Absetz&Dunbar, 2007; Absetz, Valve, Oldenburg, Heinonen, Nissinen, Fogelholm&Uutela, 2007).
The ‘Many Rivers Diabetes Prevention Project’ (MRDPP) is aimed to prevent children of Aboriginal and Torres Strait through participation in physical activities and healthy diet. This shows the efficacy of physical activity and healthy diet in the prevention of diabetes among native Australian communities. The program aimed to maintain collaboration of research governed by Aboriginal communities, bulding the capacity of Aboriginal project officers and medical services, identify the determinants of physical activity participation and healthy diet among children, develop shool based health promotion, and evaluation of the effect of the health promotion program upon knowledge of the children about diabetes, and importance of physical activity and healthy diet (Healthinfonet.ecu.edu.au., 2018).
The proposal attempts to use these pieces of evidence to plan a community-based program to promote health in the local community (Tjuntjunjtarra Community). It can be hoped that by focusing on the feasibility, cost-effectiveness, generalization options, as well as the reach, representation, implementation and adoption outcomes, the framework outlined by the proposal, can be useful for the policy makers (Glasgow, 2006). The study design can not only analyse the effectiveness of the program but also provide an opportunity to understand the contextual underpinnings of it (Catford, 2009). The main objective of the framework will be to understand the efficacy of a Community-Based plan for Health Promotion, and an additional objective is to understand its feasibility. This will help to identify the determinants as well as the cost-effectiveness and overall expense of the intervention program.
This Health Promotion model is a translational study that is underlined by International Randomized Controlled Trials, that is aimed to show how lifestyle modifications can be helpful in reduction, delay, and prevention of diabetes cases, especially among individuals at high risk. Rubio et al., (2010) points out that translational research is a part of unidirectional continuum in which the findings of the research are moved from the end of the researcher to the end of the patient. It includes two areas of translation: application of findings from discoveries and studies in the development of trials and studies in humans, and enhancing the adoption of best practices in the community. It fosters multidirectional integration of basic research, patient-oriented research, population-based research, with the aim for the improvement of public health.
A primary Healthcare Practice setup (local clinic) in Tjuntjunjtarra Community, northeast of Kalgoorlie, West Australia with assistance from the Paupiyala Tjarutja Aboriginal Corporation.
Approval must be obtained from the Western Australian Aboriginal Health Ethics Committee (WAAHEC) (Ahcwa.org.au, 2017). Informed consent must also be obtained from all the participants of the study.
The screening and selection process is adopted from the study by Colagiuri, 2010. Here, 100 General Practitioners will be selected by the General Practice Division to participate in the study. The process will be facilitated by an expression of interest through calls, emails, faxes, letters, site visits, or/and sessions. Availability of an Electronic Health Record system in the setup could also be necessary. Individuals between 50-65 years who did not have diabetes will be contacted for their participation. Different methods of identification of participants is utilized, like opportunistic recruitment (when the participants visit the GP) and using the electronic database of the provider to identify potential participants. Advertisements on local media can also be used for the invitation process.
Risk assessment is done using ‘Australian type 2 Diabetes Risk Assessment’ tool (AUSDRISK), which is a questionnaire that focuses on the demographic as well as the risk factors of diabetes (Chen, Magliano, Balkau, Colagiuri, Zimmet, Tonkin&Shaw, 2010). AUSDRISK tool has a maximum value of 38, with high risk is defined by a score of 15 or above, a risk of 14.28% is defined by a score between 15 and 19, while a score above 20 means a 33.33% risk (Chen et al., 2010). For the selected community setting, a score above 12 will be considered as high risk. Individuals screened as high risk will be investigated for existing diagnosis of diabetes by measuring the capillary blood glucose and fasting plasma glucose levels. An oral test on glucose tolerance is also to be conducted. These investigations allow the elimination of individuals who are already diagnosed with diabetes from the test, thereby selecting only the individuals with the “risk” of developing it. Individuals with hypoglycaemic medicine, weight reduction medication or having medical contradictions will be excluded from the study, and written consent must be obtained from the selected participants. The program aims to recruit 500 high-risk individuals to be provided with lifestyle management intervention.
Lifestyle Modification will have the following objectives:
The physical activity encouraged by exercise routines can promote musculoskeletal and cardiovascular fitness. The five goals were influenced by the study in Finland that experienced a tremendous success rate. The exercise routines were developed keeping in mind the other similar studies done in other countries, like strength training in the US and Finnish studies. Anaerobic exercise like resistance training is included in the program that can help in muscle development and its associated metabolic change (Wiley & Singh, 2003; Sigal, Kenny, Wasserman, Castaneda-Sceppa&White, 2006). Studies show that muscle development is also associated with an increased sensitivity to insulin, glucose balance, blood pressure, dyslipidaemia, inflammatory markers, visceral obesity, and catabolic functions of the body, thus addressing some of the most important metabolic problems associated with diabetes (Boulé, Haddard, Kenny, Wells&Sigal, 2001; Pedersen & Saltin, 2006). Additionally, resistance training can also prevent the degradation of lean tissues like muscle and bones, especially due to the administration of weight-loss medication(s) (Daly, Dunstan, Owen, Jolley, Shaw&Zimmet, 2005).
The framework of the study and evaluation process is given in the diagram below, based on the SDPP (Colagiuri et al., 2010). It outlines the activities of the general physician (GP) and participants in the study, as well as the key data studied during the process (data collection)
A Computer-AssistedTelephonic Interview (CATI) (that includes demographic and socioeconomic information, physical activity status, quality of life, self-efficacy as well as medication and healthcare usage data) is conducted on the participants, followed by a one on one counselling session with a lifestyle professional. During this time, the height, weight, and the abdominal girth of the participants are measured and recorded. The measurements are done using the standards specified by the Isakonline.com (ISAK) (ISAK, 2017). The one on one sessions aim to raise awareness of diabetes and its health effects, its preventative measures and the outline of the health promotion program, and to motivate the individuals to make independent, and healthy life choices. Next arrangements are made for groupor/and family sessions with the participantsover the next 6-8 weeks. The group sessions are aimed to highlight the importance of physical activity and healthy diet. Additionally, indigenous cultural sensitivity and awareness will also be maintained while conducting the program. At the third, sixth and ninth months, the participants are contacted again, to assess the progress of the program, and to continue the support on lifestyle modification. The participants are also provided with information on other lifestyle programs that have been proveneffective, encouraging them to enrol in more supportive programs. After 1 year, a CATI surveyand an individual assessment will be conducted again.
Health issues like Diabetes and Obesity, and risky lifestyles like lack of physical activity and unhealthy diet.
Improving physical activity, improving diet (by reducing intake of fat and incheasing intake of dietary fibre) and reduction of bodyweight.
Encouraging and supporting involvement in physical activity and improvement in diet.
Educating the community about the importance of physical excercise and healthy diet in the prevention of diabetes, obesity, cardiovascular disease and hypertension.
Truong, Pradies & Priest, (2014) pointed out that cultural competency is an effective approach to improve the providence of healthcare to racial or ethnic groups in a community and helps in reducing the racial or ethnic disparities in health. While Lin, Li & Huang, (2017) added that cultural diversity can affect the rate of progression of diseases, and therefore cultural competence of healthcare providers is important to ensure the efficacy of healthcare services.
The cultures of Aboriginal and Torres Strait Islanders are complex and diverse, and dates as far back in history as 50,000 to 65,000 years, making them the oldest cultures in the world. Their success in sustaining their culture for so long stems from their adaptability to the environment.
Different protocols and procedures thatneeds to be considered while working inpartnership with Aboriginal community includes understanding the sentiments and importance associated with Indigenous flags, Comunity Elders, Traditional Owners, and understanding of Country by the community, as wellas their various rituals and ceremonies (Australia, 2018).
Thestudy-program must involve indigenous staff, working with or as healthcare professionals involved in the consultation and follow-up processes. Community leaders can also be involved in the promotion of the program in the community, to ensure participation. Additionally, the involvement of The Paupiyala Tjarutja Aboriginal Corporation can also be crucial the delivery of effective care in the community. As per Aboriginal and Torres Strait Islander Health Performance Framework 2014 Report, involvement of local indigenous people in the design and implementation of health promotion interventions, acknowledging factors motivating individuals, building partnerships between community members and organization can be effective tools to ensure effective healthcare (Pmc.gov.au, 2018).
The evaluation plan consists of three components:
-Impact Assessment: The impact of the program is measured at 12 months, recording changes in the key elements (mentioned before); along with factors that predict the outcomes.
-Process Assessment: This is done by assessment of the feasibility, reach, fidelity, knowledge of the staff and customer satisfaction experienced by the program. Key facilitators and challenges of the process will also be identified here.
-Economy Assessment: This is done by a measurement of the costs of implantation, outcome cost, cost-effectiveness, and individual perspectives on the cost.
Assessment of outcomes is done first initially and then at the completion of 12 months of the project timeline using personal assessment and CATI questionnaire. Assessment of physical activity status is done using the Physical Activity Scale of the Elderly (PASE). Physical Activity Questionnaire is a widely used and practical way to assess physical activity of individuals (physio-pedia.com, 2018). Logan et al. (2013) suggested that body composition measures used along with PASE score can be used to develop PASE score cut points.
While the dietary intake is analysed using Foodworks (Washburn, Smith, Jette&Janney, 1993; FoodWorks, 2017). All the important key elements (discussed before) are noted in the initial and 12-month completion survey. Analysing and comparing the data can help to ascertain if the initial goals of the project were achieved, and if found effective, can be used in other communities.
This step essentially assesses if the implementation of the program is done as per the plan, reaching the target population and is feasible in the primary care setup selected for the study:
|
COMPONENT EVALUATED |
SOURCE |
TIMEFRAME |
|
Screening, participation, and recruitment |
Administrative documents from General Practice centres |
During recruitment |
|
Fidelity, completion status, intervention used |
Database |
Ongoing |
|
Awareness and engagement of staff with the program |
Telephonic questionnaires to doctors and staff |
Ongoing |
|
Barriers to recruitment and delivery |
Interview and focus group with staff |
Ongoing |
|
Problems in delivery, execution, and maintenance of program |
Focus Group with lifestyle professionals |
Ongoing |
|
Barriers to attendance in group sessions |
Via Lifestyle professionals |
After 3 months |
|
Diversity in organizational participants |
Detailed interviews with focus group and stakeholders |
End of the program (12 months) with the follow-up data. |
Economic assessment of the project can be done by calculating the total costs incurred at the Health Centre and for hiring professionals needed to execute the program (and overall expense of screening, interventions and lifestyle modification counselling), in addition of calculating the direct cost incurred by the participants themselves (like medication and healthcare visit, subscription to gyms and purchasing equipment for exercise, and loss of income due to sickness). The assessment will allow the comparison of costs between the implementation of the program and its outcomes and can be further used as a model to be implemented in other indigenous Australian communities. This will also allow the formation of a cost per kilogram of weight loss value, as a measurement of the cost-effectiveness of the program.
Statistical analysis of the data collected after 12 months will enable to assess the reach of the program by subgroup analysis. The primary data will include the status of the loss of weight, levels of physical activity, daily energy consumption and intake of dietary fibre, and the number of individuals reaching one or all the objectives. The factors that facilitate the success of the program will be identified by Logistical Regression Analysis. Last Observation Carried Forward technique is used to fill in missing data due to refusal or withdrawal of the participant. A sample of 500 individuals will be studied for 12 months detecting the following outcomes:
Conclusion:
Lifestyle issues like sedentary lifestyle, unhealthy diet have been identified as significant risk factors for diabetes as well as its co-morbidities like obesity, hypertension, cardiovascular disease and even cancer. However, lifestyle modification by increasing physical activity, improving diet (by the reduction of dietary fat intake and the increase of dietary fibre consumption) can be very effective for delaying or even preventing diabetes and its related risks. Both these findings have been supported by several authors, and intervention techniques that involve lifestyle counselling on preventative strategies have had significant successes in many studies globally. The objective of this proposal is to use this knowledge to design an effective and feasible intervention that is sustainable on the long run, to promote wellbeing in small Indigenous communities, in Australia and other countries. Furthermore, key findings of this study can also help the development of policies that are aimed towards the improvement of healthcare in Tjuntjunjtarra Community, in the future.
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