A snapshot of physical activity programs targeting Aboriginal and Torres Strait Islander people in Australia

Key words: chronic disease, participation, program evaluation.

Physical inactivity is a leading risk factor associated with the burden of disease for Australian Aboriginal and Torres Strait Islander adults.¹ Less than half of those aged 18 years and over living in non-remote areas achieved the minimum national guidelines of at least 150 min of physical activity per week, a rate lower than that of the general population.² Yet before European colonisation of Australia, an active hunter-gatherer lifestyle was evident, suggesting that more contemporary introduced factors that have contributed to current health disparities.³ Physical activity levels in Aboriginal and Torres Strait Islander children are higher than among non-Indigenous children at 48% versus 35%⁴ which may reflect higher levels of non-formal active play.

The term ‘program’ has been defined as a series of activities or events that run over a period of time, or a collection of activities or events with a particular focus.⁵ Programs designed to increase physical activity are an effective strategy to reduce chronic disease risk factors.⁶ Targeting vulnerable population groups holds particular promise given the known associations between low levels of physical activity and socioeconomic disadvantage.⁷ Considering the unique historical context and health experiences of Aboriginal and Torres Strait Islander people, culturally specific approaches to program interventions are important.⁸ Such approaches have been signalled to represent best practice by key stakeholders.⁹ Sport, health and community sectors are commonly involved in the delivery of programs, many of which claim to achieve health and social benefits through participation.

Demonstrated evidence of the effectiveness of physical activity programs for Aboriginal and Torres Strait Islander people is limited. A review published in 2004¹⁰ identified only one intervention program that achieved improvements in physical activity levels in a remote community. A more recent systematic review examined the effectiveness of group-based sport and exercise programs for Indigenous adults.¹¹ Six studies identified in the review demonstrated the effectiveness in achieving health outcomes, such as increased physical activity and reduced weight. This documentation of current program provision and scope in at-risk populations signifies the initial step required to develop the evidence base of best practice.¹² The growing rise of information available through online sources provides an opportunity to locate details on the delivery of additional programs and services. The aim of this study was to identify physical activity and sport programs targeting Australian Aboriginal and Torres Strait Islander people and to describe their characteristics including location, participant numbers and evaluation measures.

A variety of strategies were used to identify existing program information. First, the Australian Indigenous HealthInfoNet Bibliography (http://www.healthinfonet.ecu.edu.au/key-resources/bibliography, verified 12 December 2016) was searched with the health topic ‘physical activity’. Forward and backward citation tracking of articles was also conducted. Second, the HealthInfoNet’s collection of programs and projects that address physical activity among Australian Aboriginal and Torres Strait Islander peoples was also searched¹³ and the primary website link for each relevant program was located. Additional programs known to the authors were also documented and considered for inclusion.

The following inclusion criteria were applied for identified programs:

• Targets Aboriginal and Torres Strait Islander people

• 1. – Aboriginal and Torres Strait Islander specific program

  2. – Targeted Aboriginal and Torres Strait Islander component

• Program delivery includes promoting sport or physical activity participation

• 1. – Aims to increase physical activity levels for health benefits

  2. – Uses sport as a tool to improve social and community outcomes, such as education participation, reduced crime rates

• Operated in Australia at any stage from 2012 to search period (March–September 2015), reflecting current or recent practice.

Fig. 1 depicts the process of program identification and inclusion.

Fig. 1.  Flow chart of program identification and inclusion across phases 1 and 2.

Data were extracted during February and March 2015 by the lead author. For each selected program, information was collated using a structured template to document the following aspects: identification (ID) number; program name; timescale; aims; type and focus (Aboriginal and Torres Strait Islander specific or targeted element); setting (e.g. community, school); region (urban, rural or remote); target group (e.g. adults, children); number of participants; involvement of local Aboriginal and Torres Strait Islander stakeholders (yes, no or unknown); process and impact evaluation measures (e.g. physical activity and fitness level, health or social indicators); funding source (e.g. Government, private sector), cost to participants; sectors involved (e.g. health, sport); contact details.

During April–May 2015, the lead author attempted to contact coordinator(s) for each program identified in phase 1. Where an email address was available, program coordinators were sent a personalised email that contained a Microsoft Excel spread sheet of the information relevant to their program. They were asked to review, verify and return the information. If no email response was received, follow-up emails and telephone calls were made on two occasions during July–December 2015. Where telephone contact was made in the first instance, an explanation of the snapshot project was given, followed by a request for an email address to send the relevant program information. Where program coordinators offered information on additional programs that had not previously been identified by the authors, phase 1 and 2 processes were repeated for these programs.

The contact details for each program coordinator were removed to preserve anonymity. Programs were alphabetically listed within their population targeted age group categories of adults; young people and adults and young people. Data on participant numbers were summarised into four categories: 0–100 participants; 100–500 participants; 500–1000 participants; and over 1000 participants, reflecting previous categorisation in similar work.¹² Evaluation indicators were categorised as a ‘process’, such as participation or retention rates, or ‘impact’,¹⁴ for example, physical activity and fitness level; health indicators, defined as any widely recognised indicator of physical or mental health status (e.g. blood pressure, weight, diet, smoking); and social indicators, defined as any broader societal indicator of benefit (e.g. school attendance, crime rates). Descriptive characteristics were documented for each program aspect. Multiple categories were described where applicable.

The study was approved by the University of Sydney Human Ethics Review Committee (2015/149).

A total of 110 programs (Fig. 1) were included in the final results; 78 of which had information confirmed by coordinators (71%). Table 1 presents descriptive information of the program settings, population focus, costs to participants and Aboriginal and Torres Strait Islander stakeholder involvement. Table 2 outlines detailed information of the physical activity programs, including program names. The initial Bibliography search resulted in 11 relevant programs. Thirty nine programs targeted adults, 34 targeted young people and 37 targeted adults and young people. Fourteen programs operated nationally, three in the Australian Capital Territory (ACT), 21 in New South Wales (NSW), 11 in the Northern Territory (NT), 16 in Queensland (Qld) including one in the Torres Strait, two in South Australia (SA), one in Tasmania (Tas.), 12 in Victoria (Vic.), 24 in Western Australia (WA) and seven across two or more state or territory jurisdictions. Five programs commenced before 2000 and had operated continuously since starting, with one in operation since 1970. Thirty three programs commenced between 2000 and 2010, of which 21 were still operating; 35 programs commenced between 2010 and 2012, with 19 still operating. Just under a quarter of programs (n = 23) commenced between 2013 and 2015; four of which were ending by the end of 2015. One program commenced in 2009 and included an Aboriginal element from 2012. For 13 programs, the time period was unknown.

Table 1.  Setting, population focus, costs to participants and stakeholder involvement (n = 110 programs)

Table 2.  Physical activity programs targeting Aboriginal and Torres Strait Islander people
AFL, Australian Football League; ARMtour, Athletes and Role Models tour; NASCA: National Aboriginal Sporting Chance Academy; NGO, non-governmental organisation; NRL, National Rugby League; ACT, Australian Capital Territory; Qld, Queensland; NSW, New South Wales; NT, Northern Territory; SA, South Australia; Tas., Tasmania; Vic., Victoria; WA, Western Australia

Most program aims related to increasing physical activity for specific health and fitness gains, such as improving chronic disease risk factors like lowering weight and blood pressure. Nine programs focussed on social gains such as improving educational outcomes (e.g. school attendance), reducing crime rates or increasing employability. Some programs (n = 21) cited both health and social aims. Twenty five programs were conducted in all (urban, rural and remote) regions; 25 across urban and rural only; and six across rural and remote only. Fifty three programs were conducted in single regions; 27, 12 and 15 programs in urban, rural and remote regions.

Three programs claimed to reach the whole population directly. Fourteen programs involved 0–100 participants, 16 involved 100–500 participants, six involved 500–1000 participants and 22 involved over 1000 participants. Some programs documented participation numbers on an annual basis and others for the entire time period of the program. For 49 programs, the number of participants was unknown. Most programs (n = 65) included evaluation indicators: 23 had process indicators only; 22 had impact indicators only and 20 had both process and impact indicators. Of the programs with impact indicators, most measured multiple indicators: 15 examined physical activity or fitness level; 26 examined health measures such as weight or chronic disease biomarkers; 20 examined social indicators such as school attendance and two examined qualitative measures. Thirty eight programs did not have evaluation indicators and seven programs were unknown.

Forty one programs received funding from more than one source. The majority of programs (n = 86) received government support: 49 from the Australian Government, 23 of which received additional funding from other sources; 27 from state or territory governments; and nine from local government. Nine programs received funding from Aboriginal organisations such as community controlled health or medical services, four in conjunction with other sources. Around a quarter received charity or philanthropic funding (n = 25) and six received funding from non-governmental organisations (NGOs). Fourteen programs received private sector funding and one was solely funded through participant costs. For 10 programs the funding source was unknown. Almost all programs (n = 98) were delivered through partnerships across multiple sectors, comprising community, education, health, media, police, sport, local government, workplace, charities and NGOs. Nine programs charged costs to participants; two of these were initially free for 2–3 years with subsequent costs of A$2 per session. Costs for the other seven programs were typically $5 per session (n = 5) or a specific fee for a term or year.

These findings represent the first time that programs promoting physical activity among Aboriginal and Torres Strait Islander people in Australia have been documented collectively, describing patterns of current program provision. Previous reviews have elicited only a small number of relevant studies. The scope of this snapshot was programs containing published or online information only. There may be many additional programs in existence, yet without such presence information is difficult to source. However, given the increased proliferation of information available online in the past two decades, it is expected that this snapshot provides an accurate portrayal of current program provision. This is important as sharing information about program practice is an important part of effective health promotion and can serve to guide future initiatives.

The Ottawa Charter outlines a settings based approach to effective health promotion.¹⁵ We found most programs were delivered in community, followed by school, settings. Both have proven efficacy in achieving health outcomes.⁶ They are likely be particularly effective settings for reaching Aboriginal and Torres Strait Islander people given the importance of holistic health promotion and whole-of-community approaches.¹⁶ The majority of programs we identified focussed specifically on Aboriginal and Torres Strait Islander people, demonstrating provision of targeted, culturally relevant interventions; a recognised model of good practice.⁹ Given the diversity of communities and cultural groups across Australia, varied approaches to, and opportunities for, physical activity specific to local populations are required. Cultural adaptation of mainstream programs through a targeted Aboriginal element occurred in nine programs; this is also commendable as such programs have demonstrated representative reach of Aboriginal participants.¹⁷ Program participation occurred across urban, rural and remote locations. The majority of Aboriginal and Torres Strait Islander people reside in areas defined as urban, as reflected in our program location findings, despite a higher proportion living in rural or remote areas when compared with the overall Australian population.¹⁸ WA had the largest number of programs, followed by NSW and Qld; all three states have the largest population of Aboriginal and Torres Strait Islanders in Australia at 43 731, 103 907 and 94 082.¹⁸ Ten programs were located in NT, which has the highest population proportion of Aboriginal and Torres Strait Islander people at ~30%¹⁹ and the fourth highest absolute number. However, the total number of remote programs identified (n = 14) indicates gaps in program provision specific to population density are likely. While program development according to locally identified community needs is a vital component of self-determination and program success,²⁰ the widespread provision of culturally appropriate services is integral to initiatives to reduce population inequalities. It is encouraging that the majority of programs we identified involved Aboriginal and Torres Strait Islander stakeholders, as optimum program practice should encompass culturally specific input at all stages of development, implementation and evaluation.²¹

Since 2008, ‘Closing the Gap’ has been the main policy initiative to achieve Aboriginal and Torres Strait Islander health equality.²² We found that while a small number of programs had operated continuously for over a decade; the majority had shorter lifespans, limiting their sustainability. This may reflect current policy direction and typical short-term funding periods but ongoing commitment will be inherent to the success of the policy. Estimations of participant numbers were available for over half of sourced programs. Some programs had small numbers of participants (10­­–20) and others involved over 1000 people, but the extent of regular participation was unknown. Obtaining detailed information on reach and measuring its resultant impact was beyond the scope of this study, it also appeared to be beyond the scope of many of the program operations. Upstream initiatives and policies which reach larger numbers of people are likely to have greater population level effects. This has been suggested in mainstream public policy through approaching the social determinants of health²³ and is particularly pertinent for Aboriginal and Torres Strait Islander Australians.²⁴ However, current policy for disadvantaged groups focuses predominantly on individual behaviours. There is demonstrated effectiveness of group-based physical activity programs;^11,25 such practice is recommended in combination with approaches to improve broader, structural determinants of health.²⁶

We found program aims predominantly focussed on physical activity to prevent or treat chronic diseases that are the major cause of the gap in life expectancy.¹ However, the Indigenous Chronic Disease Package (ICDP) which focussed comprehensively on both the prevention and management of chronic diseases existed only from 2009–2013.²⁷ This policy change may result in fewer programs in the future, subsequently leading to poorer health in Aboriginal and Torres Strait Islander people, given the known benefits of physical activity. Almost a third of programs aimed to promote physical activity to achieve broader social benefits such as educational and employment outcomes and reduced rates of crime. Health and sport programs are worthy crime prevention approaches.²⁸ There are also recognised relationships between physical activity and fitness level and academic achievement²⁹ as well as social and mental health benefits specific to Aboriginal and Torres Strait Islander populations.^30,31 However, a cautious approach to alluding to wider social benefits directly arising from individual programs should be taken in the absence of empirical evidence, as well as the direct effects of standalone programs on health. Yet the documentation of existing program evaluation measures in this snapshot represents a vital first step in reviewing programs collectively and some have demonstrated encouraging evidence of positive educational and employment outcomes.^32,33 There is also some evidence of social benefits, such as community cohesion and cultural identity; derived from sport programs in this snapshot,^31,34 which are important for Aboriginal and Torres Strait Islander health. Such programs might therefore contribute to corresponding ‘Closing the Gap’ policy indicators and should be resourced accordingly.

Most programs received financial support from national, state, territory or local government, which is a commendable response to population health disparities. However, funding sources across multiple jurisdictions also often lack long-term synergy and support. Sustainable program funding is challenging but more likely to be achieved where public, private and philanthropic sources can be combined, as was found for several programs. While financial contributions from participants can ensure continuation, this may not be appropriate for this population group given income inequalities.³⁵ Cost has been identified as a barrier to physical activity participation among Aboriginal and Torres Strait Islander people,³⁶ therefore, it is encouraging that the majority of programs incurred no participant costs. Multi-sector partnerships, evident for the majority of programs, can help ensure continuous support across organisations.

All 11 programs identified in the bibliography search included formal evaluation results. Yet of the 110 programs sourced, 65 had formal evaluation measures; the results of which cannot be found in academic literature. This discrepancy could be partly due to evaluation proposals currently in their infancy with results anticipated in the future, as well as a lag time before findings are published. There is an increasing requirement from funding sources to conduct formal evaluation of programs³⁷ which may translate to published results in the future. However, such program evaluation results may not be made publically available. Recommendations to improve the collection of quality evaluation data³⁸ may also be influencing current practice. The low number of published evaluations represents a current gap in the sharing of evidence informed practice and rigorous science. No economic evaluations were uncovered; this also represents an avenue for future research to support ongoing investment in programs. While the purpose of this snapshot was to capture evaluation measures rather than results, findings suggest that evaluation of physical activity programs for Aboriginal and Torres Strait Islander people is more prevalent than published literature suggests. In order to ensure program effectiveness and future planning, the dissemination in a timely manner of well-designed process and impact evaluations,¹⁴ through formal and informal publication and media channels, is essential.

Strengths of this study include the comprehensive inclusion of relevant physical activity programs targeting Aboriginal and Torres Strait Islander people and the standardised documentation and description of program aspects. The inclusion of both published literature and online or grey sources enhances the scope and completeness of this work. Verification by program coordinators adds further accuracy to the findings. There are some limitations; other programs may exist, but their information was unable to be sourced. Given the widespread current use of the Internet to profile organisational information, we can be confident that the majority of existing, relevant programs were captured. The snapshot could only identify organised programs yet Aboriginal and Torres Strait Islander people may be more likely than non-Indigenous people to achieve physical activity through incidental means,³⁰ via necessary transport related activity associated with socioeconomic disadvantage³⁹ and within mainstream programs.¹⁷ Contact with some program coordinators was not possible and some differences in the understanding of program indicator information may have occurred.

This snapshot provides a comprehensive description of current physical activity program provision for Aboriginal and Torres Strait Islander people across Australia, representing an important first step in monitoring the implementation of programs to increase physical activity. Such programs are an essential part of closing the gap in health disparities.

Over 100 programs were found to be operating between 2012 and 2015 but identification of the majority of programs occurred through non-academic sources. It is recommended that all programs targeting Aboriginal and Torres Strait Islander people disseminate publically accessible details. This would provide a more complete picture of program provision, identify gaps in services and shared information platform on components of programs that could benefit populations in other locations. Many programs collect evaluation data, yet this data is commonly underrepresented in academic literature. The timescale of programs may be limited by short funding cycles, possibly affecting their overall impact and not typically allowing economic provision for analysis of program effects when programs are increasingly required to show cost benefits. Culturally appropriate, sustainable and effective programs to improve chronic disease risk factors, such as physical activity initiatives, are an integral element of efforts to improve health for Indigenous communities.