‘No sugar’, ‘no junk food’, ‘do more exercise’ – moving beyond simple messages to improve the health of Aboriginal women with Hyperglycaemia in Pregnancy in the Northern Territory – A phenomenological study

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.

Clinical practice guidelines on physical activity and exercise for pregnant women with gestational diabetes mellitus: A systematic review

AIM

This review aimed to appraise clinical guidelines about exercise for women with gestational diabetes mellitus and summarize consensus and inconsistent recommendations.

BACKGROUND

Exercise is an effective non-pharmacological therapeutic for gestational diabetes mellitus, but the variety of relevant clinical practice guidelines is confusing for healthcare professionals.

DESIGN

This is a systematic review of clinical practice guidelines.

DATA SOURCES

Websites of guideline development institutions, eight literature databases and organizations of obstetricians, gynaecologists, midwives, and medical sports associations were searched for guidelines published from January 2011 to October 2021.

REVIEW METHODS

Two reviewers independently extracted recommendations. Four reviewers assessed guideline quality using the AGREE II instrument independently.

RESULTS

Fifteen guidelines were included. All women with diabetes are recommended to exercise during pregnancy. The consistent recommendations were for pre-exercise screening, for 30 min per exercise session on 5 days of the week or every day after meals, exercise at moderate intensity, using aerobic and resistance exercise, and walking. The main non-consistent recommendations included warning signs for women on insulin during exercise, minimum duration per session, intensity assessment, duration and frequency of sessions for strengthening and flexibility exercise and detailed physical activity giving birth.

CONCLUSIONS

Guidelines strongly support pregnant women with diabetes to exercise regularly. Research is needed to make non-consistent recommendations clear.

Health System Enablers and Barriers to Continuity of Care for First Nations Peoples Living with Chronic Disease

Introduction

Failings in providing continuity of care following an acute event for a chronic disease contribute to care inequities for First Nations Peoples in Australia, Canada, and Aotearoa (New Zealand).

Methods

A rapid narrative review, including primary studies published in English from Medline, Embase, PsycINFO, and Cochrane Central, concerning chronic diseases (cancer, cardiovascular disease, chronic kidney disease, diabetes, and related complications), was conducted. Barriers and enablers to continuity of care for First Nations Peoples were explored considering an empirical lens from the World Health Organization framework on integrated person-centred health services.

Results

Barriers included a need for more community initiatives, health and social care networks, and coaching and peer support. Enabling strategies included care adapted to patients' cultural beliefs and behavioural, personal, and family influences; continued and trusting relationships among providers, patients, and caregivers; and provision of flexible, consistent, adaptable care along the continuum.

Discussion

The support and co-creation of care solutions must be a dialogical participatory process adapted to each community.

Conclusions

Health and social care should be harmonised with First Nations Peoples' cultural beliefs and family influences. Sustainable strategies require a co-design commitment for well-funded flexible care plans considering coaching and peer support across the lifespan.

The needs and experiences of women with gestational diabetes mellitus from minority ethnic backgrounds in high-income nations: A systematic integrative review

BACKGROUND

Gestational diabetes mellitus (GDM) represents a growing challenge worldwide, with significant risks to both the mother and baby that extend beyond the duration of the pregnancy and immediate post-partum period. Women from ethnic minority groups who access GDM care in high-income settings face particular challenges. The aim of this systematic integrative review is to explore the experiences and needs of women with GDM from select ethnic groups in high-income healthcare settings.

METHODS

For the purposes of this systematic integrative review, a comprehensive search strategy explored the electronic databases CINAHL, Medline, Web of Science, and Scopus were searched for primary studies that explored the needs and experiences of women with gestational diabetes from select ethnic minority groups living in high-income nations. The ethnicity of the women in the study included: East, South and Southeast Asian, Indian subcontinent, Aboriginal/First Nations, Torres Strait Islander, Pacific Islander, Māori, Middle Eastern, African, or South/Latina American. Studies were assessed with the Crowe Critical Appraisal Tool and findings were synthesised with thematic analysis.

RESULTS

This review included 15 qualitative studies, one mixed method, and one cross-sectional study. Six high-income nations were represented. The voices and experiences of 843 women who originated from at least one ethnic minority group are represented. Four major themes were constructed: psychological impact of GDM, GDM care and education, GDM and sociocultural impact, and GDM and lifestyle changes.

DISCUSSION AND CONCLUSION

Limitations exist in the provision of culturally appropriate care to support the management of GDM in women from select ethnic groups in high-income healthcare settings. Women require care that is culturally appropriate, considering the individual needs and cultural practices of the woman. Engaging a woman's partner and family ensures good support is provided. Culturally appropriate care needs to be co-designed with communities so that women are at the centre of their care, avoiding a one-size-fits-all approach.

Seeking Sweetness: A Systematic Scoping Review of Factors Influencing Sugar-Sweetened Beverage Consumption in Remote Indigenous Communities Worldwide

It is well-established that remote Indigenous communities have higher rates of sugar-sweetened beverage (SSB) consumption than non-Indigenous counterparts, which results in higher rates of chronic diseases such as type 2 diabetes mellitus (T2DM), obesity, and kidney disease. The aetiology leading to this behaviour remains understudied and overlooked. Therefore, the aim of this literature review is to understand the underpinning factors that contribute to SSB consumption in remote Indigenous communities. Studies were identified through five databases (n = 2529) and grey literature searching (n = 54). Following the PRISMA guidelines, each paper was assessed for eligibility, which left 34 studies for inclusion in the review. Within these papers, 37 different factors were found to influence SSB consumption in remote Indigenous communities. These were organised according to the Determinants of Nutrition and Eating (DONE) framework. SSB consumption was found to influence intake through each main level of the framework; individual (n = 9), interpersonal (n = 18), environmental (n = 9), and policy (n = 3). Preference was identified to be the most common factor to influence intake (n = 19), followed by health literacy (n = 15) and community availability (n = 12). Despite this, interventions to reduce SSB intake have never targeted this factor. This paper highlights the importance of a multi-level whole-of-system approach and suggests that an individual’s taste/preference should shape the direction of future research and intervention in this area.

A scoping review of gestational diabetes mellitus healthcare: experiences of care reported by pregnant women internationally

Background

Gestational diabetes mellitus (GDM) is a condition associated with pregnancy that engenders additional healthcare demand. A growing body of research includes empirical studies focused on pregnant women’s GDM healthcare experiences. The aim of this scoping review is to map findings, highlight gaps and investigate the way research has been conducted into the healthcare experiences of women with GDM.

Methods

A systematic search of primary research using a number of databases was conducted in September 2021. Studies were included if they had an explicit aim of focusing on GDM and included direct reporting of participants’ experiences of healthcare. Key data from each study was extracted into a purposely-designed form and synthesised using descriptive statistics and thematic analysis.

Results

Fifty-seven articles were included in the analysis. The majority of studies used qualitative methodology, and did not have an explicit theoretical orientation. Most studies were conducted in urban areas of high-income countries and recruitment and research was almost fully conducted in clinical and other healthcare settings. Women found inadequate information a key challenge, and support from healthcare providers a critical factor. Experiences of prescribed diet, medication and monitoring greatly varied across settings. Additional costs associated with managing GDM was cited as a problem in some studies. Overall, women reported significant mental distress in relation to their experience of GDM.

Conclusions

This scoping review draws together reported healthcare experiences of pregnant women with GDM from around the world. Commonalities and differences in the global patient experience of GDM healthcare are identified.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04931-5.

"I Don't Really Know What Diabetes Is": A Qualitative Study Exploring the Experiences of Aboriginal and Torres Strait Islander Young People Aged 10 to 25 Years Living With Type 2 Diabetes in Northern and Central Australia

OBJECTIVE

Our aim in this study was to gain an understanding of the experiences of Aboriginal and Torres Strait Islander young people aged 10 to 25 years with type 2 diabetes (T2D) living in Northern and Central Australia.

METHODS

In this qualitative study we explored participants' experiences of T2D using a social constructionist epistemology and a phenomenologic methodology. Twenty-seven young people participated in semistructured in-depth interviews from 4 primary health-care sites.

RESULTS

Three major constructs emerged. Young people experienced a normalisation-shame paradox in response to their diagnosis (partly related to that "everyone has diabetes," as well as the fear that friends "might judge [me]"), had suboptimal levels of understanding of T2D ("I don't really know what diabetes is. I just need somebody to explain to me a bit more") and experienced multiple barriers inhibiting their T2D management. These included complex lives ("I have a rheumatic heart disease […] then they told me that I have diabetes…I have two things") and the availability of support ("[I] talk to my mum…I talk to my aunty too…I don't talk to anyone else"). Successful management requires support from health professionals and family and includes strengthening social networks and educational opportunities.

CONCLUSIONS

Our findings reinforce the need for alternative support systems tailored to the specific needs of young Aboriginal and Torres Strait Islander people with T2D. Enhanced models of care must be codesigned with young people and their communities and include a focus on shifting norms and expectations about youth T2D to reduce diabetes stigma and broaden social support and consider the delivery of health information in youth-friendly environments.

A community-based program to reduce acute rheumatic fever and rheumatic heart disease in northern Australia

BACKGROUND

In Australia's north, Aboriginal peoples live with world-high rates of rheumatic heart disease (RHD) and its precursor, acute rheumatic fever (ARF); driven by social and environmental determinants of health. We undertook a program of work to strengthen RHD primordial and primary prevention using a model addressing six domains: housing and environmental support, community awareness and empowerment, health literacy, health and education service integration, health navigation and health provider education. Our aim is to determine how the model was experienced by study participants.

METHODS

This is a two-year, outreach-to-household, pragmatic intervention implemented by Aboriginal Community Workers in three remote communities. The qualitative component was shaped by Participatory Action Research. Yarning sessions and semi-structured interviews were conducted with 14 individuals affected by, or working with, ARF/RHD. 31 project field reports were collated. We conducted a hybrid inductive-deductive thematic analysis guided by critical theory.

RESULTS

Aboriginal Community Workers were best placed to support two of the six domains: housing and environmental health support and health navigation. This was due to trusting relationships between ACWs and families and the authority attributed to ACWs through the project. ACWs improved health literacy and supported awareness and empowerment; but this was limited by disease complexities. Consequently, ACWs requested more training to address knowledge gaps and improve knowledge transfer to families. ACWs did not have skills to provide health professionals with education or ensure health and education services participated in ARF/RHD. Where knowledge gain among participant family members was apparent, motivation or structural capability to implement behaviour change was lacking in some domains, even though the model was intended to support structural changes through care navigation and housing fixes.

CONCLUSIONS

This is the first multi-site effort in northern Australia to strengthen primordial and primary prevention of RHD. Community-led programs are central to the overarching strategy to eliminate RHD. Future implementation should support culturally safe relationships which build the social capital required to address social determinants of health and enable holistic ways to support sustainable individual and community-level actions. Government and services must collaborate with communities to address systemic, structural issues limiting the capacity of Aboriginal peoples to eliminate RHD.

Improving systems of prenatal and postpartum care for hyperglycemia in pregnancy: A process evaluation

OBJECTIVE

To identify successes to date and opportunities for improvement in the implementation of a complex health systems intervention aiming to improve prenatal and postpartum care and health outcomes for women with hyperglycemia in pregnancy in regional and remote Australia.

METHODS

A qualitative evaluation, underpinned by the RE-AIM framework (reach, effectiveness, adoption, implementation, maintenance), was conducted mid-intervention. Semi-structured interviews were conducted with the participants, who included clinicians, regional policymakers and managers, and study implementation staff.

RESULTS

Interviewees (n = 45) reported that the early phase of the intervention had resulted in the establishment of a clinician network, increased clinician awareness of hyperglycemia in pregnancy, and improvements in management, including earlier referral for specialist care and a focus on improving communication with women. Enablers of implementation included existing relationships with stakeholders and alignment of the intervention with health service priorities. Challenges included engaging remote clinicians and the labor-intensive nature of maintaining a clinical register of women with hyperglycemia in pregnancy.

CONCLUSION

The early phase of this health systems intervention has had a positive perceived impact on systems of care for women with hyperglycemia in pregnancy. Findings have informed modifications to the intervention, including the development of a communication and engagement strategy.