TITLE: PABCAR Evidence Informed Investigation for Health Promotion Action
Targeting Type 2 Diabetes Mellitus among Aboriginal peoples in Derby, Western
Australia.

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School/Department: School of Public Health

Date Due: xxxxxx 2020
I declare that this assignment is my own work and has not been submitted in any form for
another unit, degree or diploma at any university or other institute of tertiary education.
Information derived from the published or unpublished work of others has been
acknowledged in the text and a list of references is given. I warrant that any disks and/or
computer files submitted as part of this assignment have been checked for viruses.
Date: xxxxxx 2020
Contents
Page
1.0 Introduction 1
2.0 What is the problem and is it significant? 2
3.0 Is it amenable to change? 5
4.0 Are the intervention’s benefits greater than costs? 6
5.0 Is there an acceptance for the intervention? 7
6.0 Recommended Actions 9
7.0 References 12
1
1.0 Introduction
The PABCAR decision-making model developed by Maycock et al. (2001) can be used to
frame health promotion (HP) strategies and approaches for health issues that require
advocacy for change or intervention. The purpose of this report is to investigate Type 2
Diabetes Mellitus (T2DM) in Aboriginal peoples in the town of Derby in Western Australia
(WA).
Derby is a town in the Kimberley region of Western Australia approximately 2,350 km from
Perth and is classified by the Australian Bureau of Statistics as very remote (Marley et al.,
2012; Anderson et al., 2018, p.4). The population of the Kimberley region is approximately
36,392 in 2016 (Anderson et al., 2018, p. 4), with 65% of those residing in the Derby-West
Kimberley Shire identifying as Aboriginal Australian (Australian Bureau of Statistics, 2016).
Derby is listed as the fifth most disadvantaged local government area in WA (Australian
Bureau of Statistics, 2013). Remote settings such as Derby potentially create high risk
environments for developing diseases, associated with limited access to health services, low
socioeconomic status and cultural factors (Azzopardi et al., 2012).
T2DM is a chronic, preventable condition characterised by the body’s resistance to insulin,
leading to hyperglycaemia (Mann & Truswell, 2017), and is associated with complications
such as cardiovascular disease and renal failure (Commonwealth of Australia, 2015, p.8).
Risk factors for diabetes include overweight and obesity, poor diet, low levels of physical
activity, and smoking, in addition to genetic predisposition (Australian Institute of Health and
Welfare, 2018).
Australian Aboriginals experience a higher rate of T2DM compared to non-Aboriginal
Australians, with many burdened with the preventable disease before the age of 25 (Seear
et al., 2019). At a national level, Australian Aboriginals are three times more likely to
experience T2DM and six times more likely to die from the disease (Burrow et al, 2016). In
The Kimberley, Australian Aboriginals are significantly more likely to die from diabetesrelated causes than non-Aboriginal populations (Anderson et al., 2018). Intervention
regarding T2DM among remote Indigenous Australian populations is crucial (Burrow & Ride,
2016, p.3).
2
2.0 What is the problem and is it significant?
Health disparities between Indigenous and non-Indigenous populations is of continual
concern (Fazelipour & Cunningham, 2019). It is understood that the impact of colonisation,
with persisting inequities in social and environmental determinants associated with T2DM
contribute to a higher prevalence of diabetes in Australian Aboriginals (Ride, 2017).
Traditional historical, cultural, social, environmental practices and Indigenous Australian’s
connection to country such as the hunter gatherer lifestyle has reduced over time due to a
growing ‘Westernised’ lifestyle (Burrow & Ride, 2016; Rural Health West, 2017). Insufficient
housing, poor nutrition, reduced education and physical activity, associated with low income,
unemployment rates and racism contribute to the health disparity (Ride, 2017; Rural Health
West, 2017). Despite the recognition of poorer health outcomes of Aboriginal peoples in
remote areas, there is a continued lack of access to health services (Ride, 2017).
At a national level, the prevalence of diabetes in remote Australian Aboriginal adults
populations was significantly higher than in non-remote populations (21% compared to 9%),
with rates of newly diagnosed diabetes being more than five times higher in remote areas
(4.8%) than non-remote areas (0.9%) (AHMAC, 2017, p.56). Within WA, there is insufficient
documentation of diabetes rates within this region to truly demonstrate the prevalence of
T2DM (Health Networks Branch, 2012). Approximately 12% of deaths in Aboriginal peoples
aged 0 to 74 years in the Kimberley region were due to diabetes in the period 2006-2015,
being the third leading cause of death for Aboriginal peoples in the region (standardised rate
ratio of 1.12 compared to the WA general population) (Anderson et al., 2018, p.58).
Additionally, renal failure and ischaemic heart disease were the leading causes of death in
Aboriginal peoples over the age of 45 in the remote Kimberley region including Derby. The
study population were significantly more likely to die from diabetes than the general WA
population (16% and 2.9% respectively), and diabetes and renal failure combined accounted
for 28% of deaths (Hyde et al., 2018, p. 6). However, it is recognised that diabetes is not a
leading cause of death in the general WA population (Hyde et al., 2018).
There are a number of partners and stakeholders within the target population. Local
Aboriginal elders, businesses and community members can impact and support community
decision making (Straw et al., 2019). Community partnerships involving health care
providers can have a positive effect on participation levels of Australian Aboriginals through
screening and education in managing T2DM (Harch et al., 2012). Partnerships that
recognise the cultural context and importance of community and family are valued (Harch et
al., 2012).
3
Derby Aboriginal Health Service (DAHS) is an Aboriginal community-controlled health
service that has served the Derby community since 1998 (Marley et al., 2012). DAHS has
previously been engaged in diabetes prevention and HP for young Aboriginal peoples under
25 years, with a focus on practical skills including cooking, exercise and healthy diets (Seear
et al., 2019). Additionally, DAHS have provided general health services including visitations
from doctors, dietitians, diabetes educators and Aboriginal Health Workers (AHW) (Marley et
al., 2012).
There are three General Practitioner branches within the Kimberley, however much of the
diabetes care is provided by community health services and Aboriginal medical services.
There are high presentation rates to hospital emergency departments and inpatient services
for diabetes treatment rather than frequent use of non-emergency community-based
services (Health Networks Branch, 2012).
Living in a remote community is identified as a risk to the development of T2DM, with many
barriers to managing the disease impacting on how the problem manifests in a community
(Azzopardi et al., 2012). Genetic susceptibility, intergenerational effects, food insecurity and
decreased physical activity, low socioeconomic status link with an increase in the incidence
of obesity and T2DM (Taylor et al., 2013; Mann & Truswell, 2017). Food insecurity is
complex relating to accessibility, availability and acceptability of food including food literacy,
cooking skills and transport (Germov & Williams, 2017).
Delivery of health services can be limited including means of travel, resources and high
turnovers of health care professionals in remote settings (Azzopardi et al., 2012).
Sociocultural impacts in the Australian Aboriginal community including potential shame of
developing the disease can mean avoidance of attending medical facilities, and lack of
culturally appropriate care models leading to Aboriginal peoples feeling uncomfortable
(Azzopardi et al., 2012). Trust is imperative for health care to be provided in a culturally
appropriate manner.
Costs to the community associated with medical, life expectancy, quality of life and healthy
foods impact the significance of T2DM in Aboriginal peoples living in remote communities.
Sinclair et al. (2016) discuss the Goldfields Region of WA and the need for health services in
remote communities. With low government funding for health services, consultation fees and
medications, it places a burden on an already disadvantaged low socioeconomic community
to engage personal finances to improve their health and quality of life (Sinclair et al., 2016).
4
As previously mentioned, pressure is exerted on hospitals with increased intake of patients
with T2DM increasing hospitalisation costs, when this disease should be managed by
primary health care services (Health Networks Branch, 2012).
Death rates from T2DM are potentially avoidable through the use of primary health care and
educational intervention services (WA Country Health Service, 2018). Loss of family and
loved community members can cause trauma perhaps leading to damage of trust within the
healthcare system including a reduction of community participation and engagement (Rural
Health West, 2017). Early intervention and disease management may increase life
expectancy among the population and reduce trauma and medical costs to patients and the
health care system (Rural Health West, 2017). The costs to the community highlight the
importance of the need for intervention among this target population using programs which
are culturally appropriate and address community perceptions of the problem.
Community perceptions outlined by Webster et al. (2017) found four key areas which
impacted on the prevalence and approach to T2DM including the introduction to a
Westernised diet and lifestyle, family history, previous experiences and level of care from the
health and medical system (Webster et al., 2017). The diagnosis of many participants within
the study was either opportunistic or through hospitalisation due to complications associated
with diabetes (Webster et al., 2017).
Seear et al. (2019a) found that young men from the Australian Aboriginal community in
Derby who administered lifestyle changes to prevent diabetes were motivated by their
understanding of the complications of diabetes and the risk of premature death. They also
identified diabetes as a potentially life-long condition and were motivated to avoid this in their
own lives. However, the research revealed that participants did not perceive themselves to
be at risk of diabetes when they were younger, indicating a potential gap in understanding of
the risk and impact of diabetes at an individual level.
Similarly, Straw et al. (2019) discussed Aboriginal peoples living in remote Kimberley
communities who indicated misunderstanding a diagnosis of diabetes. There was minimal
education around the medication given, why it was consumed, or treating side-effects (Straw
et al., 2019). However, many participants felt the medications did help their symptoms, the
research highlighted the lack of communication had informed health care workers what must
be changed to close such a gap (Straw et al., 2019). The problem of T2DM among
Australian Aboriginals in Derby is a significant problem which must be addressed, further
sections will discuss ways to advocate the need for change.
5
3.0 Is it Amenable to Change?
Providing education and addressing risk factors for diabetes through HP initiatives is crucial
for diabetes prevention in the Aboriginal population (Ride, 2017). A range of HP activities
addressing diabetes and diabetes risk factors in remote Aboriginal populations have been
implemented within Australia.
An eight-week physical exercise and dietary prevention program was piloted in Derby to
encourage positive lifestyle changes. Participants reported improved dietary behaviours,
including consuming more vegetables, reducing intake of fatty foods and sugary drinks and
drinking more water (Seear et al., 2019). Evaluation of the program also indicated an
increase in participants’ motivation to be screened for diabetes (Seear et al., 2019). The
success of the program was attributed to the group format, length of the program, Aboriginal
facilitators and venue (Seear et al., 2019). Seear et al. (2019) noted for future programs
changes could be made to increase participation. These included greater flexibility in
sessions, childminding facility, provision of Aboriginal specific resources and adjustments to
increase consistency in attendance (Seear et al., 2019).
Mendham et al. (2015) implemented a 12-week sports-based exercise programme involving
small sided sport and group exercise programs. The programs resulted in a decrease in
insulin resistance and a decrease in abdominal density (Mendham et al., 2015). Attendance
rate averaged at 69% with attendance in the second half of the course dropping from 73% to
65% (Mendham et al., 2015, p.440).
Participants’ attendance was attributed to the provision of positive reinforcement, transport if
required and group activity as opposed to individual programs (Mendham et al., 2015). The
program was also developed in partnership with local Aboriginal community members
(Mendham et al., 2015). Mendham et al. (2015) noted the importance of using BMI and
abdominal density measurements with caution as Aboriginal people are predisposed to
acquiring fat deposits in this area.
The Aboriginal Medical Service Western Sydney provided a series of cooking courses
ensuring there was culturally appropriate affordable food available, avoiding unfamiliar
ingredients and teaching techniques (Abbott et al., 2012). The Aboriginal participants in the
study believed the cooking course demonstrated how dietary changes can be made,
focussing on behaviour related tasks and self-efficacy (Abbott et al., 2012). Aboriginal
people were more likely to attend the course because of its large social component,
6
especially the enjoyment of socialising with other Aboriginal participants (Abbott et al.,
2012).
4.0 Are the Intervention’s Benefits Greater Than Costs?
Diabetes is associated with significant economic and health-related costs for remote
Aboriginal communities, including those in the Kimberley and Derby areas (Anderson et al.,
2018; Hyde et al., 2018). In remote Northern Territory, costs associated with preventing a
single hospitalisation for diabetes in the primary care setting were significantly less than
those associated with hospital admission (between $248 and $739 compared to $2,915,
respectively) (Thomas et al., 2014, p. 661). Importantly, it has been identified that Aboriginal
people are up to four times more likely to be hospitalised for T2DM-related conditions
compared to non-Aboriginal populations, and people in remote and very remote areas are
up to two times as likely to be hospitalised for T2DM compared to those in major cities
(AIHW, 2018, p. 120).
Additional to the financial burden of disease, is the emotional, social and cultural costs
where health implications relating to T2DM experienced by Aboriginal populations are met
with fear (Sinclair et al., 2016). Relocation for treatment, financial burden, cultural
displacement and separation from family, are major concerns to Aboriginal communities and
individuals often choose to decline treatment, dying within their community (Sinclair et al.,
2016, p. 307). Aboriginal Australians do not consider health to be individualistic, rather
incorporating the emotional and cultural wellbeing of their community (Teng Liaw et al.,
2011).
King at el. (2013) recognises the importance of acceptable HP practices in communities
advising that an Aboriginal community benefited from HP practitioners involving community
and educating younger populations on healthy eating and cooking strategies regarding
T2DM prevention. Seear et al. (2019) discussed education and skills are likely to be
disseminated throughout communities in an informal manner, increasing interventions’
benefits. However, there are very few published interventions relating to adolescent
Aboriginal Australians highlighting a need for development of community based
appropriately designed interventions for this target group (Seear et al., 2019a).
While the benefits of preventing diabetes in the community are evident, funding has been
identified as a key issue for assessing the practicality of diabetes HP programs in the
community. Seear et al. (2019) discuss while an eight-week diabetes prevention program
delivered in the Derby area was well received and had modest benefits for participants in
7
terms of diet, a lack of funding negatively impacted on the sustainability of the program. The
authors concluded that long-term funding is necessary to make interventions viable and
sustainable for communities to implement (Seear et al., 2019). Additional to economic
factors, individual community needs must be addressed. Successful community engagement
techniques such as utilisation of appropriate community leaders and assessment of
community readiness must be determined (King et al., 2013). There has been limited
published studies explaining successful community engagement strategies and effective
cultural understanding, further research is required to determine long term benefits to
communities (King et al., 2013).
Gwynn et al. (2019) advised store-based interventions appear to be effective in some
remote communities. The cost of fresh food, sometimes 30% higher than rural locations is a
burden to community members leading to the purchase of cheaper, highly processed energy
dense foods containing saturated fats, increased salt and sugar (Germov & Williams, 2017).
If fresh protein, fruit and vegetables are available, it is questioned whether food is culturally
appropriate and of high quality and variety (Germov & Williams, 2017). An increase in poor
foods generates an elevated risk of developing T2DM especially in remote communities
(Mann & Truswell, 2017). The involvement of Community Leaders for healthy food provision
in stores is an effective method of community and government collaboration further
promoting sustainability of interventions in communities (King et al., 2013; Sinclair et al.,
2016). Further investigation into discounting food and food subsidies is required, to ensure
there are no economic disadvantages for local businesses and benefits to the government
and to the consumer are provided (Gwynn et al, 2019).
5.0 Is There an Acceptance for the Intervention?
Diabetes prevention interventions have been successfully implemented and accepted in
other remote Aboriginal communities, however direct consultation with the Derby community
is necessary to identify local perceptions and needs. To ensure the appropriateness and
acceptance of interventions proposed for addressing and preventing T2DM in Derby, it must
be recognised that culturally appropriate methodology should be employed when working
with Aboriginal communities (Demaio et al., 2012).
Demaio et al. (2012) have identified eight principles of culturally appropriate HP actions,
which provide guidance for HP practitioners in ensuring programmes are respectful of local
communities, utilising their skills and knowledge, and providing sustainable and holistic
change. These include: “community involvement, consultation and empowerment; socioculturally tailored HP techniques; community evaluation and feedback in real time; utilisation
8
of local communication techniques; maximisation of both the spoken word and the local
tongue; sustainable health development and community health autonomy; holistic in nature,
addressing the needs of the whole person; and, spirituality and social connectedness as
health determinants” (p.59). With these principles in mind, a number of interventions that
have previously been delivered and assessed as being acceptable, both in Derby, and in
similar Aboriginal communities, can be explored.
A pilot diabetes prevention program previously delivered in Derby and based at DAHS was
found to be acceptable (Seear et al., 2019), with participants reporting that, “it was good to
have this program in Derby” (p.497) and reporting changes in diet and knowledge about
diabetes. The program included education about the risk factors and consequences of
T2DM, exercise and healthy diets, with the inclusion of practical activities to support good
health.
Research by Colles et al. (2014) in a remote Aboriginal community in the Northern Territory
found a strong preference for learning practical skills and information about food and
cooking. Preferred settings for HP opportunities included schools, community events, and
through families. Guidance is offered for potential features of interventions addressing diet
and nutrition knowledge to enhance acceptability.
Schoen et al. (2010) found that paper-based HP resources, including pictures, were the
preferred method of communicating HP messages for Aboriginal peoples regarding diabetic
food care. Posters were popular, and other mediums such as mugs with pictures on them
were favoured. Simple, succinct messages, and the use of local language were favoured,
with participants preferring to create their own HP messages. These findings align with
recommendations made by Demaio et al. (2012) and offer insights into possible
considerations for the creation of acceptable diabetes-related HP resources in the Derby
setting.
Yarning is a culturally appropriate and acceptable communication method within health
practices and HP settings (Lin et al., 2016). Using a yarning style approach to deliver HP
activities about T2DM may be considered in the Derby setting, in consultation with the
community.
Munro et al. (2017) found that a radio-based HP campaign addressing substance use in a
remote Aboriginal community in NSW was effective in raising awareness of the health harms
of substance use in the community. Radio advertisements were a “relevant and well-trusted”
avenue for communication resulting in high recall of HP messages (p. 296). Seventy-five
9
percent of respondents recalled at least one advertisement from their campaign (p. 296),
with 22% of participants reporting an increase in help seeking (p.296). While these findings
are not specific to diabetes, the potential for a radio-based campaign to be considered in
addition to other diabetes HP and prevention approaches in Derby, given the high level of
recall and acceptability observed in this study.
Gwynn et al. (2019) suggest store-based interventions including discounts for healthy foods,
which in one population, saw an increase in the purchase of fruit and vegetables.
Implementation of a community-led nutrition policy observed dietary related health
improvements, however income management strategies administered by the federal
government did not. Conversely, this government-led intervention saw an increase in the
purchase of soft drinks and no change in the market of fruits and vegetables (Gywnn et al.,
2019). This case illustrates the need for community-led approaches to enhance acceptability
and efficacy.
Some Aboriginal communities request more frequent visitation by “sensitively structured and
integrated programs” and advocacy for increased health services in remote communities
(Sinclair et al., 2016, p. 312). Advocacy enhances grant application assistance, and the
availability of healthy foods in roadhouses and shops to improve communities (Sinclair et al.,
2016). These examples illustrate interventions that are considered acceptable in enhancing
healthy environments and behaviours. Intervention adaptations are required to
accommodate the needs and preferences of the community, for example by increasing
service access and providing advocacy support and skills to local communities.
6.0 Recommended actions
Aboriginal peoples residing in remote locations, have poorer health outcomes, reduced life
expectancies, and greater rates of T2DM in Australia in comparison to non-Aboriginal
Australians (Sinclair et al., 2016; AHMAC, 2017). Despite this, the Australian Federal
Government has previously withdrawn funding to several Aboriginal health programs
(Sinclair et al., 2016). Gwynn et al. (2019) advise that the “Closing the Gap” strategy largely
failed in its goal of reducing the disadvantage of Aboriginal Australians. This strategy did not
acknowledge the importance of nutrition or food security, largely associated with the
development of T2DM, and evidently the risk of T2DM among Aboriginal Australians living in
Derby must be addressed.
Health information delivered to Aboriginal communities can be unidirectionally delivered from
a HP provider. Aboriginals peoples tend to agree with a health professional, regardless of
whether the information was truly understood, reducing the self-efficacy of individuals to
10
manage interventions and desired health outcomes (Forbes et al., 2010). Forming
relationships and trust between health providers and individuals must be enabled to address
communication barriers, cultural sensitivity, and effective recognition of chronic disease risk
factors (Fazelipour & Cunningham, 2019).
Effective and vigorous engagement in Aboriginal communities is challenging as cultural
differences and resistance to new interventions and policy changes may arise (Gwynn et al.,
2019). Long term sustainable interventions which emphasise on cultural values and
empowerment, potentially take several years of planning and development to truly
successfully engage with communities (Fazelipour & Cunningham, 2019; Sinclair et al.,
2016). Health interventions are respected when reflecting upon the opinions of community
Elders and integrating Aboriginal health workers to aid effective communication, therefore
increasing community participation (Sinclair et al., 2016).
Fazelipour & Cunningham (2019) identified gaps in literature including lack of current studies
pertaining to Indigenous-specific behavioural interventions, with a paucity of published
evidence concerning nutrition and physical activity levels in Indigenous populations. Within
Australia, the majority of published data primarily involves short term studies with absent
literature on long-term management (Marley et al., 2012). Sinclair et al. (2016) recognise the
difficulty in assessing an intervention’s effectiveness being due to acceptance of the
intervention or the community relationships being drawn upon (Sinclair et al., 2016).
However, it is imperative that any intervention be designed to address individual community
needs (Seear et al., 2019).
Based on the preceding PABCAR assessment, the following recommendations are made to
guide HP actions addressing T2DM in Aboriginal peoples in Derby, Western Australia:
1. Culturally appropriate ways of working in HP must be prioritised in any HP activity
undertaken in Derby to address T2DM (Demaio et al., 2012).
2. The Aboriginal community in Derby must be consulted, and HP and prevention
activities should be identified, designed, delivered and evaluated with input from the
community at all stages of the process. Trusting and respectful relationships should
be a cornerstone of this engagement (Fazelipour & Cunningham, 2019).
3. HP approaches previously found to be effective in other similar communities may be
considered in the Derby setting. These include: discounts on healthy foods (Sinclair
et al., 2016); the use of programs that include education and practical skills (Seear et
al., 2019), including cooking skills (Abbott et al., 2012; Colles et al., 2014); the use of
paper-based HP resources incorporating local language and designed with the local
11
community (Schoen et al., 2014); exercise-based programs (Mendham et al., 2015);
and, yarning sessions to deliver HP messages with the community (Lin et al., 2016).
Concepts such as these could be presented to the Aboriginal community in Derby for
consideration based on local needs and preferences (Seear et al., 2019).
4. The importance of funding and the need for increased and ongoing funding to ensure
the sustainability of HP programs in Aboriginal and remote settings has been
identified (Seear et al., 2019; Sinclair et al., 2016). In consultation with the
community, it may be appropriate to advocate for increased funding for diabetes
prevention and HP services in Derby.
5. Other advocacy opportunities may be identified in Derby. Previous research has
identified the need for advocacy in relation to the availability of healthy foods and
grant application assistance (Sinclair et al., 2016). The need for advocacy support
should be explored with the local Derby community, to identify beneficial areas.
6. Previous research identified gaps in literature in relation to the efficacy of subsidies
for health foods (Gwynn et al., 2019). Continuously consider this when approaching
HP and prevention for T2DM in Derby, and may be an area for further work in this
setting.
7. The employment of Aboriginal health workers to deliver HP activities should be
prioritised (Sinclair et al., 2016), in agreement with the community.
8. Given the current lack of published evidence about long-term nutrition and exercise
interventions (Marley et al., 2012), there may be benefit in investigating longer-term
approaches to T2DM HP in Derby, with a view to explore the efficacy and impact of
these interventions over time. The desire and need for these approaches would need
to be thoroughly explored with the local community.
Word Count: 4186
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