Supporting healthy lifestyles for First Nations women and communities through co-design: lessons and early findings from remote Northern Australia.

Background: The period before, during, and after pregnancy presents an opportunity to reduce diabetes-related risks, which in Australia disproportionately impact Aboriginal and Torres Strait Islander women. Collaboration with Aboriginal and Torres Strait Islander women/communities is essential to ensure acceptability and sustainability of lifestyle modifications. Using a novel co-design approach, we aimed to identify shared priorities and potential lifestyle strategies. We also reflected on learnings from this approach. Methods: We conducted 11 workshops and 8 interviews at two sites in Australia's Northern Territory (Central Australia and Top End), using experience-based co-design (EBCD) and incorporating principles of First Nations participatory research. Workshops/interviews explored participant' experiences and understanding of diabetes in pregnancy, contextual issues, and potential lifestyle strategies. Participants included three groups: 1) Aboriginal and Torres Strait Islander women of reproductive age (defined as aged 16-45 years); 2) Aboriginal and Torres Strait Islander community members; and 3) health/community services professionals. The study methodology sought to amplify the voices of Aboriginal women. Findings: Participants included 23 women between ages 16-45 years (9 with known lived experience of diabetes in pregnancy), 5 community members and 23 health professionals. Key findings related to identified priority issues, strategies to address priorities, and reflections on use of EBCD methodology. Priorities were largely consistent across study regions: access to healthy foods and physical activity; connection to traditional practices and culture; communication regarding diabetes and related risks; and the difficulty for women of prioritising their health among competing priorities. Strategies included implementation of a holistic women's program in Central Australia, while Top End participants expressed the desire to improve nutrition, peer support and community awareness of diabetes. EBCD provided a useful structure to explore participants' experiences and collectively determine priorities, while allowing for modifications to ensure co-design methods were contextually appropriate. Challenges included the resource-intensive nature of stakeholder engagement, and collaborating effectively with services and communities when researchers were "outsiders". Conclusions: A hybrid methodology using EBCD and First Nations participatory research principles enabled collaboration between Aboriginal women, communities and health services to identify shared priorities and solutions to reduce diabetes-related health risks. Genuine co-design processes support self-determination and enhance acceptability and sustainability of health strategies.

Conceptualisation, experiences and suggestions for improvement of food security amongst Aboriginal and Torres Strait Islander parents and carers in remote Australian communities.

This study aimed to determine perceptions of the lived experience of food insecurity and suggestions to improve food security in four remote Aboriginal communities in the Northern Territory, and Queensland. Participants were Aboriginal and/or Torres Strait Islander pregnant and breastfeeding women, and parents/carers of children aged six months to five years. Semi-structured interviews (n=17) were conducted between June-July 2021 and the data thematically analysed using a four stage process. No specific term was used by participants to describe being either food secure or insecure. Descriptions of food security were centred in food sharing, food sufficiency, and family activities. Elements describing food insecurity were physical pain and emotional stress, adults going without food, seeking family help and managing without food until payday. Factors contributing to food insecurity were reported to be: (i) Low income and unemployment, (ii) Cost of living remotely, (iii) Resource sharing, and (iv) Impact of spending on harmful commodities and activities. Three themes were conceptualised: (1) Cultural practices buffer food insecurity, (2) Coping with food insecurity, (3) People accept a degree of food insecurity as normal. Findings suggest Aboriginal and Torres Strait Islander cultural practices such as sharing food buffer episodic food insecurity and constitute 'cultural food security'. Despite use of cultural practices (e.g., procuring traditional food) and generic coping strategies, regular episodes of food insecurity often aligned with the off week of social assistance payments. Household energy (electricity) security was coupled to food security. Suggestions for improving food security included better transport and food access, extending electricity rebates, increases in the regularity of social assistance payments, and computer access and training in budgeting. Policies to advance food security should embody deeper Aboriginal and Torres Strait Islander descriptions and experiences. Community-derived policy suggestions which aim to increase access to adequate, regular, stable household income are likely to succeed.

The Adaptation of a Youth Diabetes Prevention Program for Aboriginal Children in Central Australia: Community Perspectives.

This study reports on integrating community perspectives to adapt a family-focused, culturally appropriate behavioural intervention program to prevent diabetes among Aboriginal children (6-11 years) in Central Australia. A participatory action research approach was used to engage a range of service providers, cultural advisors, and family groups. Appropriateness, acceptability, content, and delivery of a prevention program within the Central Australian context were discussed through a series of workshops with twenty-five service providers and seven family groups separately. The data obtained were deductively coded for thematic analysis. Main findings included: (i) the strong need for a diabetes prevention program that is community owned, (ii) a flexible and culturally appropriate program delivered by upskilling community members as program facilitators, and (iii) consideration of social and environmental factors when implementing the program. It is recommended that a trial of the adapted prevention program for effectiveness and implementation is led by an Aboriginal community-controlled health service.

Exploring differences in perceptions of child feeding practices between parents and health care professionals: a qualitative study.

BACKGROUND: Evidence on child feeding practice is often based on the perspectives and experiences of parents and less that of health practitioners. In this study, we explored child feeding practice in Aboriginal communities in northern Australia from both the parents and health practitioners' perspectives with the aim of informing nutrition improvement programs. METHODS: Qualitative research methods were employed. Using semi-structured interviews, parents (n = 30) of children aged 2-5 years, and 29 service providers who were involved in the delivery of child health and nutrition programs in the same communities, were asked about child feeding attitudes and practices. Responses were analyzed through inductive and deductive analysis, recognizing that worldviews influence child feeding practices. RESULTS: Sharing food was a central practice within families. Parents highly valued development of child independence in food behavior but were conflicted with the easy access to unhealthy food in their communities. This easy access to unhealthy food and inadequate food storage and kitchen facilities for some families were major challenges to achieving optimal diets for children identified by Aboriginal families and service providers. The responsive style of parenting described by parents was often misunderstood by service providers as sub-optimal parenting when viewed through a dominant western lens. CONCLUSIONS: Approaches to support healthy feeding practices and optimal child nutrition require health-enabling food environments. Along with a community-based Aboriginal health workforce, it is paramount that the non-Aboriginal workforce be supported to be reflective of the impact of worldview on their practice, to ensure a culturally safe environment for families where parenting styles are understood and appropriately supported.

Influences on drinking choices among Indigenous and non-Indigenous pregnant women in Australia: A qualitative study.

Despite women's awareness that drinking alcohol in pregnancy can lead to lifelong disabilities in a child, it appears that an awareness alone does not discourage some pregnant women from drinking. To explore influences on pregnant women's choices around alcohol use, we conducted interviews and group discussions with 14 Indigenous Australian and 14 non-Indigenous pregnant women attending antenatal care in a range of socioeconomic settings. Inductive content analysis identified five main influences on pregnant women's alcohol use: the level and detail of women's understanding of harm; women's information sources on alcohol use in pregnancy; how this information influenced their choices; how women conceptualised their pregnancy; and whether the social and cultural environment supported abstinence. Results provide insight into how Indigenous Australian and non-Indigenous pregnant women understand and conceptualise the harms from drinking alcohol when making drinking choices, including how their social and cultural environments impact their ability to abstain. Strategies for behaviour change need to: correct misinformation about supposed 'safe' timing, quantity and types of alcohol; develop a more accurate perception of Fetal Alcohol Spectrum Disorder; reframe messages about harm to messages about optimising the child's health and cognitive outcomes; and develop a holistic approach encompassing women's social and cultural context.

Parent Feeding Practices in the Australian Indigenous Population within the Context of non-Indigenous Australians and Indigenous Populations in Other High-Income Countries-A Scoping Review.

Although extensive literature on parent feeding practices among the general Australian population exists, Australian Indigenous populations are generally overlooked. A systematic scoping review was carried out to map any source of literature showing Indigenous parent feeding practices in Australia in the context of what is known about parent feeding practices among broader Australian populations and Indigenous populations in other high-income countries.A search of 8 electronic health databases was conducted. Inclusion criteria were children aged <12 y and reporting ≥1 child outcome related to childhood overweight and/or obesity, body mass index, dietary intake, or eating behavior in the context of parent feeding practices. Studies were grouped according to Indigenous status of the population for data extraction and synthesis.A total of 79 studies were identified; 80% (n = 65) were conducted among the general Australian population and <20% (n = 14) focused on Indigenous populations. Although a wide range of feeding practices were identified among the general Australian population, Indigenous practices most closely aligned with highly responsive and permissive parenting dimensions. The highly valued child autonomy in Indigenous parenting is sometimes criticized by researchers when viewed through a Western lens because the child has agency in deciding what and when to eat.Evidence-based understanding and knowledge of Indigenous parent feeding practices in Australia are limited. Indigenous worldviews are expressed distinctly differently than the general Western worldview in parent feeding practices. How worldviews are represented in parent-child relationships is important to consider for the way in which research with Indigenous populations is conducted and the evidence it generates to inform policy and practice.

Food Security Experiences of Aboriginal and Torres Strait Islander Families with Young Children in An Urban Setting: Influencing Factors and Coping Strategies.

Evidence on Aboriginal and Torres Strait Islander peoples' food security experiences and coping strategies used when food insecurity occurs is limited. Such evidence is important to inform policies that can reduce the consequences of food insecurity. This study investigated factors perceived by Aboriginal and Torres Strait Islander families with young children to influence household food security, and coping strategies used, in an urban setting. A qualitative research inductive approach was used. Data were collected through an iterative process of inquiry through initial interviews with 30 primary care-givers, followed by in-depth interviews with six participants to further explore emerging themes. Major topics explored were: influencing factors, food insecurity experiences, impact on food selection, and coping strategies. Food affordability relating to income and living expenses was a major barrier to a healthy diet with large household bills impacting food choice and meal quality. Access to family support was the main reported coping strategy. Food insecurity is experienced by Aboriginal and Torres Strait Islander families, it is largely intermittent occurring especially when large household bills are due for payment. Family support provides an essential safety net and the implications of this are important to consider in public policy to address food insecurity.

Strengths and limitations of a tool for monitoring and evaluating First Peoples' health promotion from an ecological perspective.

BACKGROUND: An ecological approach to health and health promotion targets individuals and the environmental determinants of their health as a means of more effectively influencing health outcomes. The approach has potential value as a means to more accurately capture the holistic nature of Australian First Peoples' health programs and the way in which they seek to influence environmental, including social, determinants of health. METHODS: We report several case studies of applying an ecological approach to health program evaluation using a tool developed for application to mainstream public health programs in North America - Richard's ecological coding procedure. RESULTS: We find the ecological approach in general, and the Richard procedure specifically, to have potential for broader use as an approach to reporting and evaluation of health promotion programs. However, our experience applying this tool in academic and community-based program evaluation contexts, conducted in collaboration with First Peoples of Australia, suggests that it would benefit from cultural adaptations that would bring the ecological coding procedure in greater alignment with the worldviews of First Peoples and better identify the aims and strategies of local health promotion programs. CONCLUSIONS: Establishing the cultural validity of the ecological coding procedure is necessary to adequately capture the underlying program activities of community-based health promotion programs designed to benefit First Peoples, and its collaborative implementation with First Peoples supports a human rights approach to health program evaluation.