Evaluation of a pragmatic community-tailored physical activity program with Aboriginal and Torres Strait Islander people

Sushames, Ashleigh (2018) Evaluation of a pragmatic community-tailored physical activity program with Aboriginal and Torres Strait Islander people. PhD thesis, James Cook University.

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The health inequalities between Indigenous and non-Indigenous Australians, and the benefits of physical activity in the prevention and treatment of chronic diseases are well known. Yet, little research has been conducted on physical activity and health outcomes for Aboriginal and Torres Strait Islander people. The Australian physical activity guidelines, recommend that adults should accumulate 150-300 minutes per week of moderate activity or 75-150 minutes of vigorous activity or equivalent combinations of both. Currently, 47% of Aboriginal and Torres Strait Islanders in non-remote locations are sufficiently physically active, 0.9 times that of non-Indigenous Australians.

The purpose of this thesis was to investigate ways to improve the health of Indigenous Australians through a physical activity program. The first major aim (Study 1) was to synthesise previous evaluations of physical activity interventions implemented with Indigenous people in Australia and New Zealand and, based on this, to identify gaps in the literature and to recommend an agenda for future research in this field. The second aim (Study 2) was to assess the reliability and validity of the Fitbit Flex for measuring physical activity levels, as this device would be used in the succeeding study. The Fitbit Flex was selected as the comparative device as it is a waterproof accelerometer that can be worn 24 hours a day as a wristband, which may be more convenient for users and was hypothesised to lead to higher compliance in wearing time than the waist worn Actigraph GTX3+. The third aim was to implement and evaluate an 8-week community-tailored physical activity program in a rural and regional setting. The quantitative part of the evaluation of the program (Study 3) involved assessing changes in functional capacity for exercise, physical activity and various health outcomes. In a qualitative study (Study 4) barriers and enablers to participating in the program were examined.

Study 1: The systematic review was registered with the PROSPERO network and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive search of the literature identified 13 studies which met the inclusion criteria. Due to the heterogeneity of the data and the contexts in which they were collected a meta-analysis was not feasible, so a narrative synthesis of the results was conducted. Only six studies measured physical activity objectively (n=2) or via self-report (n=4) and only five studies measured a component of fitness such as strength or sub-maximal aerobic capacity. There was no clear evidence that the interventions had increased activity levels in the shortterm. However, 11 out of 13 studies reported improvements in fitness and other physical activity-related health outcomes such as reductions in weight and blood pressure.

Study 2: A gap identified in the systematic review (Study 1) was the lack of objective measurements of physical activity, where only two out of the 13 studies had used pedometers. Therefore, in Study 2 the Fitbit Flex, a novel accelerometer, was validated against direct observation and a research-grade accelerometer (Actigraph GTX3+) under laboratory and free-living conditions. The validity of the Fitbit Flex was found to be dependent on the type of activity, where the number of steps taken during jogging and stair stepping were more accurate, compared to slow walking activities which were undercounted. The Fitbit Flex had overall moderate validity, was deemed more cost-effective and, due to the lower participant burden was expected to lead to higher compliance in wearing time. Consequently, the Fitbit Flex was selected as the method for objectively measuring activity levels of the participants in the planned physical activity program (Study 3).

Study 3: In line with the recommendations from the systematic review, objective measures of activity with the Fitbit Flex were attempted in the evaluation of the physical activity intervention (Study 3). The primary outcome measure for the community-tailored 8-week physical activity program was the change in functional capacity, which was assessed by the six-minute walk test (6MWT).

The physical activity program was implemented in both a rural (n=12) and regional community (n=22) in Far North Queensland. An attempt was made to use a wait-listed control group, however, the intended site withdrew shortly before the intervention was to begin due to a lack of staff availability. Due to an insufficient number of participants and therefore lack of statistical power, the original plan to run the evaluation with a waitlisted control group had to be replaced with a pre-post study design. An intention to treat analysis was undertaken due to low program attendance. In the rural community, there was a 50% attrition rate, where six of the 12 participants completed follow-up assessment. There was a significant improvement in the 6MWT distance from 467.3 metres±56 to 557.8 metres±108 (p=0.01) and significant decreases in body fat (34.98±6.6% to 30.61%±6.92, p=0.009) and hip circumference (106.6cm±4.0 to 104cm±5.3, p=0.005). Attendance to the program was low. Eight participants did not attend a single training session, and four attended an average of seven out of 26 sessions. Six sessions were cancelled due to rain which affected the implementation of the program.

In the regional city, 18 of the 22 participants attended post-program assessments. There was an increase in the 6MWT distance, but this was not clinically significant (p=0.287). There were no significant reductions in weight (p=0.25), BMI (p=0.19) or body fat percentage (p=0.85). Significant reductions were measured in waist circumference (from 99.11cm±11.95 to 96.07cm±11.46 (p=0.006) and hip circumference (from 105.41cm±11.32 to 101.97cm±8.83 (p=0.019)). Reductions in both systolic (p=0.0002) and diastolic blood pressure (p=0.0002) were also evident. No significant improvements in pathology markers, such as HbA1c or cholesterol, were evident. Unfortunately, the objectively measured physical activity data could not be used for the evaluation of the intervention due to poor compliance in wearing the Fitbit Flex accelerometres. Self-reported daily minutes of moderate to vigorous physical activity increased from 28.2 minutes ± 13.3 to 40 minutes ± 20.2 (p=0.09), but this was not significant.

Study 4: After observing low attendance to the physical activity program, a qualitative evaluation was undertaken to better understand the factors that were influencing the attendance rate. Semi-structured interviews were conducted with twelve participants at the follow-up health assessments for Study 3. The interview guide was loosely based on the Health Belief Model. It was theorised that individuals would be more likely to voluntarily engage in the physical activity program if their current behaviour is perceived as a threat to their health. The findings from the interviews confirmed that despite low program attendance, there were positive attitudes and high levels of motivation towards the physical activity program. The enablers to participation were the inclusion of family members, no financial cost and a good relationship with the principal investigator, which was strengthened by the community-based participatory approach to the program design. Barriers to program attendance were mostly beyond the control of the individuals, such as sorry business, needing to travel away from the community and lack of community infrastructure.

Conclusion: The purpose of this thesis was to investigate ways to improve the health of Indigenous Australians through a physical activity program. Based on the findings from the systematic review of the literature and the validation study, an 8-week physical activity program was implemented. The results of the program suggest that those who participated in physical activity during the study period had improvements in clinical health outcomes. However, more consideration of community-specific barriers and enablers is needed prior to implementation of programs to understand how they will affect attendance to the program. More work is needed to better understand how to improve participation rates in physical activity programs for Aboriginal and Torres Strait Islander people in rural and regional settings.

Item ID: 56915
Item Type: Thesis (PhD)
Keywords: Australia, chronic disease, exercise, Fitbit, health inequality, Indigenous health, indigenous, intervention, New Zealand, physical activity, remote health, rural health
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Copyright Information: Copyright © 2018 Ashleigh Sushames
Additional Information:

Publications arising from this thesis are available from the Related URLs field. The publications are:

Chapter 2: Sushames, Ashleigh, van Uffelen, Jannique G.Z., and Gebel, Klaus (2016) Do physical activity interventions in Indigenous people in Australia and New Zealand improve activity levels and health outcomes? A systematic review. International Journal of Behavioral Nutrition and Physical Activity, 13. pp. 1-16.

Chapter 3: Sushames, Ashleigh, Edwards, Andrew, Thompson, Fintan, McDermott, Robyn, and Gebel, Klaus (2016) Validity and reliability of Fitbit Flex for step count, moderate to vigorous physical activity and activity energy expenditure. PLoS ONE, 11 (9). pp. 1-14.

Chapter 6: Sushames, Ashleigh, Engelberg, Terry, and Gebel, Klaus (2017) Perceived barriers and enablers to participation in a community-tailored physical activity program with indigenous Australians in a regional and rural setting: a qualitative study. International Journal for Equity in Health, 16.

Date Deposited: 16 Jan 2019 23:27
FoR Codes: 11 MEDICAL AND HEALTH SCIENCES > 1106 Human Movement and Sports Science > 110699 Human Movement and Sports Science not elsewhere classified @ 30%
11 MEDICAL AND HEALTH SCIENCES > 1117 Public Health and Health Services > 111701 Aboriginal and Torres Strait Islander Health @ 40%
11 MEDICAL AND HEALTH SCIENCES > 1117 Public Health and Health Services > 111712 Health Promotion @ 30%
SEO Codes: 92 HEALTH > 9203 Indigenous Health > 920302 Aboriginal and Torres Strait Islander Health - Health Status and Outcomes @ 40%
97 EXPANDING KNOWLEDGE > 970111 Expanding Knowledge in the Medical and Health Sciences @ 30%
92 HEALTH > 9204 Public Health (excl. Specific Population Health) > 920499 Public Health (excl. Specific Population Health) not elsewhere classified @ 30%
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