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

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

Do physical activity interventions in Indigenous people in Australia and New Zealand improve activity levels and health outcomes? A systematic review

Background: Indigenous Australians and New Zealanders have a significantly shorter life expectancy than non-Indigenous people, mainly due to differences in prevalence of chronic diseases. Physical activity helps in the prevention and management of chronic diseases, however, activity levels are lower in Indigenous than in non-Indigenous people. Objective: To synthesise the literature on the effects of physical activity interventions for Indigenous people in Australia and New Zealand on activity levels and health outcomes. Methods: The Cochrane Library, MEDLINE, SPORTSDiscus and PsycINFO were searched for peer-reviewed articles and grey literature was searched. Interventions targeted Indigenous people in Australia or New Zealand aged 18+ years and their primary or secondary aim was to increase activity levels. Data were extracted by one author and verified by another. Risk of bias was assessed independently by two authors. Data were synthesised narratively. Results: 407 records were screened and 13 studies included. Interventions included individual and group based exercise programs and community lifestyle interventions of four weeks to two years. Six studies assessed physical activity via subjective (n = 4) or objective (n = 2) measures, with significant improvements in one study. Weight and BMI were assessed in all but one study, with significant reductions reported in seven of 12 studies. All five studies that used fitness tests reported improvements, as did four out of eight measuring blood pressure and seven out of nine in clinical markers. Conclusions: There was no clear evidence for an effect of physical activity interventions on activity levels, however, there were positive effects on activity related fitness and health outcomes

Hair cortisol, allostatic load, and depressive symptoms in Australian Aboriginal and Torres Strait Islander people

Chronic stress and adversity are associated with poor mental health and are thought to contribute to the existing mental health gap between Aboriginal and Torres Strait Islander people and other Australians. Hair cortisol and allostatic load (AL) are indices of sustained stress and may be mediators of the effects of stress on health. The aim of this study was to examine the relationship between hair cortisol, AL, and depressive symptoms. This cross-sectional study comprised 329 Aboriginal and Torres Strait Islander adolescents and adults recruited at two health screening programs operating in three communities in north Queensland. We measured hair cortisol and calculated an AL index from 10 biomarkers. We assessed depressive symptoms with a version of the Patient Health Questionnaire-9 adapted for Aboriginal and Torres Strait Islander people (aPHQ-9). We found differences in cortisol and AL between the screening programs and communities, which were not explained by depressive symptoms. Overall aPHQ-9 scores were unrelated to hair cortisol (p = .25 and p = .94) and AL (p = .30 and p = .88) when age, gender and smoking were taken into account. However, anhedonia (p = .007) and insomnia (p = .006) sub-scores were each significantly associated with AL in one study site. Our present data did not demonstrate overall associations of stress biomarkers and multisystem dysregulation with depressive symptoms, which suggests that the relationship between cumulative stress and depression may be better explained by other factors in this population. The specific association between anhedonia and insomnia with AL indicates that chronic multisystem dysregulation plays a role in these features of depression in this population

Validity and reliability of fitbit flex for step count, moderate to vigorous physical activity and activity energy expenditure

Objectives: To examine the validity and reliability of the Fitbit Flex against direct observation for measuring steps in the laboratory and against the Actigraph for step counts in free-living conditions and for moderate-to-vigorous physical activity (MVPA) and activity energy expenditure (AEE) overall. Methods: Twenty-five adults (12 females, 13 males) wore a Fitbit Flex and an Actigraph GT3X+ during a laboratory based protocol (including walking, incline walking, running and stepping) and free-living conditions during a single day period to examine measurement of steps, AEE and MVPA. Twenty-four of the participants attended a second session using the same protocol. Results: Intraclass correlations (ICC) for test-retest reliability of the Fitbit Flex were strong for walking (ICC = 0.57), moderate for stair stepping (ICC = 0.34), and weak for incline walking (ICC = 0.22) and jogging (ICC = 0.26). The Fitbit significantly undercounted walking steps in the laboratory (absolute proportional difference: 21.2%, 95%CI 13.0-29.4%), but it was more accurate, despite slightly over counting, for both jogging (6.4%, 95%CI 3.7-9.0%) and stair stepping (15.5%, 95%CI 10.1-20.9%). The Fitbit had higher coefficients of variation (Cv) for step counts compared to direct observation and the Actigraph. In free-living conditions, the average MVPA minutes were lower in the Fitbit (35.4 minutes) compared to the Actigraph (54.6 minutes), but AEE was greater from the Fitbit (808.1 calories) versus the Actigraph (538.9 calories). The coefficients of variation were similar for AEE for the Actigraph (Cv = 36.0) and Fitbit (Cv = 35.0), but lower in the Actigraph (Cv = 25.5) for MVPA against the Fitbit (Cv = 32.7). Conclusion: The Fitbit Flex has moderate validity for measuring physical activity relative to direct observation and the Actigraph. Test-rest reliability of the Fitbit was dependant on activity type and had greater variation between sessions compared to the Actigraph. Physical activity surveillance studies using the Fitbit Flex should consider the potential effect of measurement reactivity and undercounting of steps

Do physical activity interventions in Indigenous people in Australia and New Zealand improve activity levels and health outcomes? A systematic review

BACKGROUND: Indigenous Australians and New Zealanders have a significantly shorter life expectancy than non-Indigenous people, mainly due to differences in prevalence of chronic diseases. Physical activity helps in the prevention and management of chronic diseases, however, activity levels are lower in Indigenous than in non-Indigenous people. OBJECTIVE: To synthesise the literature on the effects of physical activity interventions for Indigenous people in Australia and New Zealand on activity levels and health outcomes. METHODS: The Cochrane Library, MEDLINE, SPORTSDiscus and PsycINFO were searched for peer-reviewed articles and grey literature was searched. Interventions targeted Indigenous people in Australia or New Zealand aged 18+ years and their primary or secondary aim was to increase activity levels. Data were extracted by one author and verified by another. Risk of bias was assessed independently by two authors. Data were synthesised narratively. RESULTS: 407 records were screened and 13 studies included. Interventions included individual and group based exercise programs and community lifestyle interventions of four weeks to two years. Six studies assessed physical activity via subjective (n = 4) or objective (n = 2) measures, with significant improvements in one study. Weight and BMI were assessed in all but one study, with significant reductions reported in seven of 12 studies. All five studies that used fitness tests reported improvements, as did four out of eight measuring blood pressure and seven out of nine in clinical markers. CONCLUSIONS: There was no clear evidence for an effect of physical activity interventions on activity levels, however, there were positive effects on activity related fitness and health outcomes. TRIAL REGISTRATION: The review protocol was registered with PROSPERO (registration number: CRD42015016915 ).status: publishe

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

Abstract Background Aboriginal and Torres Strait Islander people have higher rates of chronic disease and a lower life expectancy than non-Indigenous Australians. In non-urban areas these health disparities are even larger. The aim of this qualitative study was to explore perceived barriers and enablers to attending an eight-week physical activity program in a rural and regional setting which aimed to improve health outcomes, but had a low attendance rate. Methods Thirty-four Indigenous Australians participated in the intervention from the rural (n = 12) and the regional (n = 22) community. Qualitative semi-structured individual interviews were conducted at the follow-up health assessments with 12 participants. A thematic network analysis was undertaken to examine the barriers and enablers to participation in the program. Results Overall, there were positive attitudes to, and high levels of motivation towards, the physical activity program. 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. Conclusions More consideration is needed prior to implementation of programs to understand how community-specific barriers and enablers will affect attendance to the program. Trial registration ACTRN12616000497404 . Registered 18 April 2016

Bland-Altman plots of walking steps for the Fitbit and Actigraph compared to direct observation.

<p>Bland-Altman plots of walking steps for the Fitbit and Actigraph compared to direct observation.</p

Comparisons and differences of direct observation and the Fitbit in the laboratory and the Fitbit and Actigraph in free living.

<p>Comparisons and differences of direct observation and the Fitbit in the laboratory and the Fitbit and Actigraph in free living.</p

Validity and Reliability of Fitbit Flex for Step Count, Moderate to Vigorous Physical Activity and Activity Energy Expenditure

<div><p>Objectives</p><p>To examine the validity and reliability of the Fitbit Flex against direct observation for measuring steps in the laboratory and against the Actigraph for step counts in free-living conditions and for moderate-to-vigorous physical activity (MVPA) and activity energy expenditure (AEE) overall.</p><p>Methods</p><p>Twenty-five adults (12 females, 13 males) wore a Fitbit Flex and an Actigraph GT3X+ during a laboratory based protocol (including walking, incline walking, running and stepping) and free-living conditions during a single day period to examine measurement of steps, AEE and MVPA. Twenty-four of the participants attended a second session using the same protocol.</p><p>Results</p><p>Intraclass correlations (ICC) for test-retest reliability of the Fitbit Flex were strong for walking (ICC = 0.57), moderate for stair stepping (ICC = 0.34), and weak for incline walking (ICC = 0.22) and jogging (ICC = 0.26). The Fitbit significantly undercounted walking steps in the laboratory (absolute proportional difference: 21.2%, 95%CI 13.0–29.4%), but it was more accurate, despite slightly over counting, for both jogging (6.4%, 95%CI 3.7–9.0%) and stair stepping (15.5%, 95%CI 10.1–20.9%). The Fitbit had higher coefficients of variation (C_v) for step counts compared to direct observation and the Actigraph. In free-living conditions, the average MVPA minutes were lower in the Fitbit (35.4 minutes) compared to the Actigraph (54.6 minutes), but AEE was greater from the Fitbit (808.1 calories) versus the Actigraph (538.9 calories). The coefficients of variation were similar for AEE for the Actigraph (C_v = 36.0) and Fitbit (C_v = 35.0), but lower in the Actigraph (C_v = 25.5) for MVPA against the Fitbit (C_v = 32.7).</p><p>Conclusion</p><p>The Fitbit Flex has moderate validity for measuring physical activity relative to direct observation and the Actigraph. Test-rest reliability of the Fitbit was dependant on activity type and had greater variation between sessions compared to the Actigraph. Physical activity surveillance studies using the Fitbit Flex should consider the potential effect of measurement reactivity and undercounting of steps.</p></div

Bland-Altman plots of stair steps for the Fitbit and Actigraph compared to direct observation.

<p>Bland-Altman plots of stair steps for the Fitbit and Actigraph compared to direct observation.</p