In Australia, the health disparities between indigenous (the Aboriginal and Torres Strait Islanders (ATSI)) and non-indigenous people remain unacceptably wide.

Cover page

Project Summary

In Australia, the health disparities between indigenous (the Aboriginal and Torres Strait Islanders (ATSI)) and non-indigenous people remain unacceptably wide. Some of the identified health disparities are evidentin the increased prevalence of cardiovascular disease, diabetes, mental health disorders and chronic respiratory diseases. With a focuson type 2diabetes (T2DM), the health promotion team has proposed a program designed to support the existing Australian Diabetes Association program in the fight against the disease. Educational programs have evidently been found to effectively help in the prevention and reduction of T2DMin several parts of Australia. Specific to the needs of the ATSI people, the health promotion team proposes two educational programs – knowledge-based and behavior-related in the attempt to effectively promote the fight against T2DM. To support the proposal, the team reviewed the previous literature to assess the success of education, literacy programs and cultural-oriented approaches in the prevention of T2DM. The proposal also defined the search strategies that were used in the literature review, followed by a detailed review of the literature. The proposal reviewed the community needs, identifying the design and implementation of the strategies to fight diabetes. The strengths lie in the fact that the ATSI still observe their cultural values. and introducing culturally aligned education programs may be effective in preventing diabetes. After this, the proposal adopted the five-step PRECEDE model, which provides a simple ecological approach to health promotion. Using the five steps, the proposal was able to identify social assessment and situational analysis, epidemiological assessment, educational and ecological assessment, aims and objectives, intervention alignment, and administrative and policy assessment. The model allowed the team to draw up the estimated budget proposalrequired fortheimplementation of the program. Lastly, we identified the roles, which were specific to the leader of the health promotion program.(scope of project?)

Table of Contents

Diabetes Type 2 Education Program for Aboriginal and Torres Strait Islanders 4

Identification of Health Issue/Project 6

Describe the Processes of Identifying the Health Issue that Needs Addressing in the Project 6

Literature Review 7

Search Strategies 8

Diabetes Education, Literacy Programmes, and Culturally Competent Education 8

Needs and Strengths 9

Project Planning using the Five Stage PRECEDE Model 10

Step 1: Determine the Population Needs through Social Assessment, Participatory Planning, and Situational Analysis 10

Step 2: Identifying the Health Determinants of these Needs 11

Step 3: Analyze the Behaviors and Environmental Determinants of Health Needs 11

Step 4: Identification of Project Aim and Objectives 12

Step 5: Project Budget and Implementation 13

My Role as a Leader in the Health Promotion Team 14

Health Promotion Funding Proposal

Diabetes Type 2 Education Program for Aboriginal and Torres Strait Islanders

Health disparities and the prevalence of major illnesses such as cancer, cardiovascular disease and diabetes among others have been in existence in a majority of the developed countries such as Australia, United States, Canada, and UK among others (Durey& Thompson, 2012). The prevalence of these diseases is often greater among the most vulnerable groups in society. In Australia, the Aboriginal and Torres Strait Islanders have a shorter life expectancy and worse health outcomescompared to non-indigenous people(Pippa, Melanie, & Rebecca, 2015). There is an evident health gap between indigenous and non-indigenous individuals on non-communicable diseases. Among the ATSI, cardiovascular diseases takes the lead at 23 percent, followed by diabetes at 12 percent, mental disorders at 10 percent, and chronic respiratory disease at 9 percent (Pippa eat al., p. 2). Focusing on diabetes, the Aboriginal and Torres Strait Islanders (ATSI) are almost four times more likely to have type 2 diabetes as compared to non-indigenous Australians (see appendix I and II for statistics on the prevalence of type 2 diabetes). Type 2 diabetes also begins at an earlier age among Indigenous people compared to non-indigenous people and this can mean the risk of developing complications from diabetes also begins at an earlier age (Azzopardi, Brown, & Zimmet, 2012). Additionally, the large number of people affected by T2DM is likely due to high rates of obesity, dietary changes, decreased physical activity and an aging population (Kolb& Martin, 2017). Research also indicatesT2DM is a lifestyle disease and its treatment involves lifestyle modifications for weight loss, dietary changes and increasing physical activity (Mullner, 2009). Among (ATSI communities’ successful treatment, management and prevention of T2DM encompasses a wider picture where economic, political, and social factors play a critical and important part. More specifically, it is evident the Westernised lifestyle is one of the major contributors to the development of T2DM. Research indicates that adopting a low-fat, high-fiberdiet, a physically active lifestyleand maintaining a healthy weight rangecan help improve the health status of the Aboriginal people and prevent T2DM. 

In response to the growing prevalence of T2DM, the Australian National Diabetes Strategy outlined a national response that designed various ways in which existing limited health care resources can be utilized to prevent and reduce the prevalence of diabetes. The Australian National Diabetes Strategy 2016-2020 identified some of the most appropriate and effective interventions to minimize the impact of diabetes in the community. Among the proposed goals included enhancing access to a structured self-management education program for people with diabetes. Particular attention was proposed to programs for children with diabetes, adolescents, and older people, as well as their carers. For the Aboriginal and Torres Strait Islanders, the strategy recommended the development and implementation of community-wide programs to raise awareness and communicate the seriousness of diabetes (“Australian National Diabetes Strategy2016–2020,” 2015). Unfortunately, because the proposed strategy focuses on the entire Australian community, it may not cover the whole ATSI population. Thus, we identify this as a community need and have prepared a funding proposal that will focus on introducing a diabetes education program targeting Aboriginal and Torres Strait Islanders living in the New South Wales area – Wagga Wagga region. The New South Wales, Wagga Wagga region was identified for the implementation of the education program because a high percentage of the Aboriginal populations live in this area. The health promotion program aims to support the education and awareness of type 2 diabetes, raised by the Diabetes Australia. More specifically, the health promotion program will focus on knowledge-based teaching but also behavior-related tasks. The tasks the team intends to focus on include activities to improve ATSI people’s physical exercise and cooking courses targeted at helping them make necessary dietary changes. The funding proposal will be presented to the government for funding in a bid to support the current initiatives and reduce the prevalence of type 2 diabetes among Aboriginal people in Australia.

Identification of Health Issue/Project

Describe the Processes of Identifying the Health Issue that Needs Addressing in the Project

Different factors affect the health and well-being of a community and in most cases, various entities and individuals are expected to play a role to respond to the community health needs. The health promotion team sees a requirement for a framework within the local community and proposes to take a comprehensive approach to maintain and improve the health status of the Aboriginal people. The committee intends to accomplish this by first assessing the health needs of the community, determine the resources available and the assets necessary to promote health and to help develop and implement a strategy for action to improve the community’s health status. To undertake the needs assessment, the health promotion team used four key steps. The first step was consultation, which involved talking to people living and working in the community to gain insight into the issues and concerns affecting the community. The team spoke to various people including health agencies, the public, community organizations, volunteer networks, local healthcare professionals and many others. The second step was data collection, which involved collecting data from published materials, and statistical and demographic information from various organizations in relation to the health status of Aboriginal people. The next step involved presenting the findings. The team provided anyone who participated in the planning and development of the program, with regular updates on the data collection. The community was included in the data analysis, for wider scrutiny, which assisted in the generation of the findings. They were presented in a full report for presentation to the entire team and the community. The last step in the needs assessment involved determining priorities. From the consultations, it was clear there were several issues affecting the Aboriginal community in the New South Wales area. Unfortunately, it is impossible to address all of the issues identified. A decision had to be made to prioritize one issue, while involving the community and the key stakeholders, to ensure the issue met the needs of the target group. 

Diabetes is a significant health problem in Australia, and one of the major causes of health disparities among the indigenous and non-indigenous people. According to Reeve, Church, & Haas (2014), diabetes complications contribute to various issues affecting the lives of the Aboriginal people including poor quality of life and early death. Since there is no cure for T2DM, prevention is imperative. Existing literature indicates the known risks for type 2 diabetes include poor diet, obesity, lack of physical exercise, socioeconomic disadvantages, stress, advanced age and family history (Kelly& Ismail, 2015).Overall reports about Australia indicate the proportion of people overweight or obese has not changed based on data from 2007 to 2015. (see appendix III). Other reports indicate the proportion of people not following the guidelines for physical activity has not changed, as well as the proportion of people following dietary recommendations based on data from 2007 to 2015. (see appendix IV and V). Therefore, the focus of the literature review will be placed on the Aboriginal and Torres Strait Islanders with type 2 diabetes. It will be presented in an attempt to show the immense need to increase access to literacy-sensitive, effective, and culturally appropriate diabetes education for this particular community and to increase the number of people with obesity among the ATSI

Search Strategies

The literature review was carried out to evaluate the current diabetes education practices that have helped in the fight against diabetes. The search tools used included online peer-reviewed journals (EBSCO and Jstor databases), print books and Australia Government websites. Only journals published between 2008 and 2018 were considered for review. The keyword ‘diabetes education effectiveness’ was used and only research conducted in Australia was considered to increase the relevance of the review. Reputable websites were used for definition and statistical data representation. 

Diabetes Education, Literacy Programs and Culturally Competent Education

Up until the late 18th century, the Aboriginal and Torres Strait Islanders maintained a hunter-gatherer lifestyle (Burrow, Ride, & Australian Indigenous HealthInfoNet, 2016). However, with the arrival of the Europeans in 1788, the Aboriginal community went through major lifestyle transformations. Changes in diet and physical activities played a key role in the development of diabetes, among the ATSI people, particularly during the second half of the 20th century. Currently, there is no known cure for type 2 diabetes, but it can be managed through the administration of insulin and oral anti hypoglycemics to lower or boost a patient’s blood sugar (Kotecki,2018). Unlike type 1diabeteswhich cannot be prevented, type 2 diabetes prevention is a critical component in diabetes care. In Australia, diabetes educators provide education on self-management for people with diabetes and prevention, as a way of promoting optimal health and well being. The educators work under an umbrella group known as the Australian Diabetes Educators Association (ADEA), which was founded in 1981 (King, Nancarrow, & Grace, 2017). The workforce is diverse, drawing professionals from various groups such as nurses, dietitians and pediatrics. Among the Aboriginal and Torres Strait Islanders, evidence indicates that short-term health lifestyle programs for type 2 diabetes can have positive health effects and be more effective if initiated by the community (Lee & Ride, 2018). Additionally, culturally appropriate care services and education programs have been proven effective in improving diabetes care and prevention. Research carried out to analyze the experience of ATSI people, who attended urban community courses in 2002 to 2017, indicate the course helped them to adjust their diet (Abbott, Davison, & Moore, 2012). Thus, a focus on behavior-related tasks, as opposed to knowledge-based learning, increases the success of diabetes and nutrition education. 

Another study carried out by Passmore, Shepherd, and Milat (2017), was designed to investigate the impact of community-led programs promoting weight loss and healthy living in ATSI people in New South Wales. The campaign tagged the Knockout Health Challenge was a community-led lifestyle program, where teams competed to achieve the greatest weight loss in stretch of 16-week period. The aim was to promote weight loss and healthy living through improved nutrition and increased physical activity. According to the results of the study, the state-wide program was successful. Participants were able to increase their physical activity and improve their nutrition by having more fruits and vegetables in their diet. 

Needs and Strengths

After the lifestyle change in 1788, the traditional activities associated with finding renewable food and resources changed (Burrow et al., 2016). The community also experienced adverse physical activity and nutrition changes, which played a role in the prevalence of diabetes among the ATSI people. The factors associated with the high rates of diabetes among this group are a combination of historical, social, economic, and cultural determinants. Nonetheless, despite these transformations, the ATSI people still hold strongly to their cultures. This means, introducing culturally appropriate and locally supported education programs, has a high probability of being successful in the fight against type 2diabetes. 

Project Planning using the Five Stage PRECEDE Model

Due to the high prevalence of diabetes among the ATSI people, efforts have been made to develop and evaluate various strategies to improve the diabetes health status of the Aboriginal and Torres Strait Islanders with moderate success. Evidence shows that the most effective educational programs are theory-based and take patterns from changing behavioral patterns (Moshki, Dehnoalian, & Alami, 2017). However, planning, designing and evaluating a health promotion program, based on changing the behavioral patterns of a community to impact diabetes health status, can be a challenging and time-consuming exercise. The PRECEDE model is one model used for programming behavioral changes and usually adopts a five-step process, providing a simple ecological approach to health promotion (Curley, & Vitale, 2012). Consistently, this health promotion program sought to apply the five-stage PRECEDE model on the preventive behaviors for type 2 diabetes mellitus. 

Step 1: Determine the Population Needs through Social Assessment, Participatory Planning, and Situational Analysis

The health promotion team noted that because diabetes is a lifestyle disease, changing the dietary behavior of the ATSI people and increasing their participation in physical activities, can help prevent and reduce the incidence of type 2 diabetes. Thus, to be able to define the social needs, the team collected the demographic data, which was designed to assess the prevalence of diabetes type 2 among the ATSI people in Wagga Wagga, New South Wales area, Australia. The team used community surveys, focus groups, face-to-face interviews with community administrators and healthcare professionals, and questionnaires in public places. 

Step 2: Identifying the Health Determinants of these Needs

In this phase, the team looked for issues or factors that might cause or influence the outcome identified in the first step, and selected the most important ones, which can be influenced by an intervention. Diabetes is often defined as a lifestyle disease, which requires individuals to change their dietary behavior and adopt a physically active life. In this case, it was identified that an unhealthy dietary behaviors, and a lack of physical activity were the major causes of type 2 diabetes among the ATSI. It was further identified that lack of awareness regarding healthy diet, the importance of physical activity, and level of health literacy about the risks of diabetes, were some of the major contributors to the prevalence of type 2diabetes.

Step 3: Analyze the Behaviors and Environmental Determinants of Health Needs

In this section, we analyzed the behaviors and environmental determinants that might explain the health needs of the Aboriginal and Torres Strait Islanders in Wagga Wagga, in New South Wales, Australia. By definition, environmental factors affect large groups of people sharing a common living area (Woolf, & Aron, 2013). The factors are key explanatory factors for health disparities across geographic areas. Ideally, access to clean air, water and a balanced diet in a sustainable way is a major tenet of human health. In the absence of these basic amenities, diseases and inequality is most likely to manifest unchecked. However, Knibbs and Sly (2014) noted that marginalization and a legacy of inequity have disadvantaged a high number of the indigenous people all over Australia. From a general overview, some of the environmental determinants of the health needs for the ATSI include indoor air pollution, weather and climate, contaminated water and land. On the other hand, behavioral determinants represent the single most controllable domain of influence over health (Scutchfield, Keck, & Erwin, 2016). Some of behavioral patterns that determine health include dietary patterns, physical activity, alcohol and other drug-related abuse (Skochelak, Hawkins, & Lawson, 2016). Among the Aboriginal and Torres Strait Islanders, behavioral factors associated with the prevalence of the health needs include increased tobacco and alcohol abuse, obesity, lack of physical activity and inadequate balanced diet (Knibbs& Sly, 2014).Notably, the behavioral factors can be attached to the environmental determinants in that, because the ATSI  have been marginalized for a very long time, their economic status is unstable. This means, the lack money to buy healthy foods such as fruits and vegetable, may lead them to taking unhealthy diets. 

Step 4: Identification of Project Aim and Objectives

Diabetes education programs have been widely implemented in Australia, with evidence indicating their success. The objective of this health promotion proposal is to develop a community-based educational program for Aboriginal and Torres Strait Islanders with type 2diabetes. More specifically, the proposal is aimed at implementing community-based educational programs designed to offer both knowledge-based and practical-based education to the affected community. More specifically, the project goals include educational programs and campaigns designed to help in preventing and reducing the incidence of type 2 diabetes by creating awareness about the preventive measure the community should take

Step 5: Project Budget and Implementation

The development of a detailed budget includes identifying the needs, costs and resources required to implement the health promotion plan. The budget should include a budget range of all the options required for the successful implementation of the diabetes education program. The exact budget includes the following: 

Personnel (per year)

Program Coordinator 30,000 

Administrative Assistant 6,500 

Supplies (every three months)

Educational/ Outreach 2,500 

Office Supplies 1,500

Food Supplies for Wellness Programs 3,500

Contractual (per year)

Consulting Medical Doctor 16,500

Registered Dietitian/ Diabetes Educator 18,600

Exercise Therapist 23,500

Equipment (paid once)

Laptop Computer 800

LCD Projector 1,100

Kitchen Appliances and Equipment 2,500

Total Budget Estimate 107,000

My Role as a Leader in the Health Promotion Team

The leadership position is responsible for the planning, implementation and evaluation of the health promotion program. The primary role involves managing, leading and providing the necessary professional oversight for the entire team. In this position, the leader will also play a significant role in identifying new health promotion initiatives and provide professional advice and support. Alongside this, it is expected that the leader will engage and provide strategic level support to relevant stakeholders to enable the success of the health promotion program. Other roles that the leader is expected to undertake, include ensuring appropriate monitoring and reporting, including analyzing variations, monthly reports, as well as submitting all ministry of health reporting and information requests. Supporting the delivery of health promotion outcomes including managing staff, financials and other resources, to ensure they remain within proposed budgets. I will also be responsible for engaging with and maintaining key relationships within the local communities, while ensuring cultural competency and addressing ethical issues. Understandably, this is a challenging role, particularly in maintaining cultural competency, which will require conducting a cultural audit to understand the native language, the spiritual or religious beliefs, social and economic status, and other characteristics specific to the group. Consequently, the team leader will engage an interpreter/ translator who will help the group in communicating with the  people in case they do not speak or understand English. The leader will also engage a cultural broker to get a comprehensive understanding about the cultures of the ATSI. 

Appendix I: Prevalence of Diabetes among persons aged a8 years and above classified by age and sex for 2014 to 2015.

Appendix II: Diabetes proportions of the indigenous and non-indigenous populations reporting diabetes/ high sugar-levels

Appendix III: Proportion of people overweight or obese

https://www.aihw.gov.au/getmedia/84e7bd94-ddf6-4f94-9fbc-3ccdd562a005/diabetes-indicators-overweight.png.aspx

Appendix IV: Proportion of people not following guidelines for physical activity. 

Column chart shows two in three adults did not do sufficient physical exercise in 2007-08, 2011-12 and 2014-15.

Appendix V: Proportion of people not following guidelines for physical activity

C:\Users\WANJIR~1\AppData\Local\Temp\diabetes-indicators-insufficient-diet.png.png

References

““Prevalence of diabetes, among persons aged 18 and over, by age and sex, 2014–15.” (n.d). AIHW.GOV. Retrieved from: https://www.aihw.gov.au/reports/diabetes/diabetes-compendium/contents/how-many-australians-have-diabetes

“Australian National Diabetes Strategy 2016–2020.” (2015). Australian Government: Department of Health. Retrieved from: http://www.health.gov.au/internet/main/publishing.nsf/content/3AF935DA210DA043CA257EFB000D0C03/$File/Australian%20National%20Diabetes%20Strategy%202016-2020.pdf

“Diabetes proportions of the indigenous and non-indigenous populations reporting diabetes/ high sugar-levels.” (2007) Review of diabetes among Indigenous peoples. Australian Indigenous HealthInfoNet. Retrieved from: https://healthinfonet.ecu.edu.au/uploads/docs/diabetes-review.pdf

“Proportion of people not following guidelines for physical activity.” (n.d). AIHW.GOV. Retrieved from: https://www.aihw.gov.au/reports/diabetes/diabetes-indicators/contents/summary

“Proportion of people not following guidelines for physical activity.” (n.d). AIHW.GOV. Retrieved from: https://www.aihw.gov.au/reports/diabetes/diabetes-indicators/contents/summary

“Proportion of people overweight or obese.” (n.d). AIHW.GOV. Retrieved from: https://www.aihw.gov.au/reports/diabetes/diabetes-indicators/contents/summary

Abbott, P. A., Davison, J. E., Moore, L. F., & Rubinstein, R. (2012). Effective Nutrition Education for Aboriginal Australians: Lessons from a Diabetes Cooking Course. Journal of Nutrition Education and Behavior, 44(1), 55-59.

Azzopardi, P., Brown, A., Zimmet, P., Fahy, R. E., Dent, G. A., Kelly, M. J., Kranzusch, K., … Wren, S. J. (2012). Type 2 diabetes in young Indigenous Australians in rural and remote areas: Diagnosis, screening, management and prevention. Medical Journal of Australia, 197(1), 32-36.

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King, O., Nancarrow, S., Grace, S., & Borthwick, A. (2017). Diabetes educator role boundaries in Australia: a documentary analysis. Journal of Foot and Ankle Research, 10(1), 1-11.

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Moshki, M., Dehnoalian, A., & Alami, A. (2017). Effect of precede-proceed model on preventive behaviors for type 2 diabetes mellitus in high-risk individuals. Clinical Nursing Research, 26(2), 241-253.

Mullner, R. M. (2009). Encyclopedia of health services research. Los Angeles: Sage.

Passmore, E., Shepherd, B., Milat, A., Maher, L., Hennessey, K., Havrlant, R., Maxwell, M., … Mitchell, J. (2017). The impact of a community-led program promoting weight loss and healthy living in Aboriginal communities: the New South Wales Knockout Health Challenge. Bmc Public Health, 17(1), 1-9.

Pippa, W., Melanie, P., Rebecca, B., James, D., & Michael, R. (2015). Factors Influencing the Health Behaviour of Indigenous Australians: Perspectives from Support People. Plos One, 10(11), 1-17.

Reeve, R., Church, J., Haas, M., Bradford, W., & Viney, R. (2014). Factors that drive the gap in diabetes rates between Aboriginal and non-Aboriginal people in non-remote NSW. Australian and New Zealand Journal of Public Health, 38(5), 459-465.

Scutchfield, F. D., Keck, C. W., In Erwin, P. C., & In Brownson, R. C. (2017). Principles of public health practice.Clifton Park, NY : Delmar, Cengage Learning.

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