Exploring Health Behaviours

Exploring the meaning of, the barriers to and potential strategies for promoting physical activity among urban Indigenous Australians
Julian Hunt, Alison L. Marshall, David Jenkins

Introduction
Available data clearly and consistently show Indigenous Australians have significantly lower life expectancies than other Australian men and women. This is despite the fact that the life expectancies of Indigenous men and women increased to 59 years for Indigenous males and 65 years for Indigenous females between 1996 and 2001. Unfortunately, however, these data are similar respectively to the life expectancy of the non-Indigenous Australian men in 1901-1910 and the women in 1920-1922.1 In 2002, Indigenous Australians were twice as likely to report their health was fair to poor when compared to non-Indigenous Australians. Overall Indigenous Australians experience greater mortality and morbidity from non-communicable diseases. The main cause of death among Indigenous Australians is disease of the circulatory system (heart attacks, heart failure

and stroke).2 The age-standardised prevalence of diabetes/high sugar levels among Indigenous people was 3.4 times the rate in non-Indigenous people (ABS 2006). Indigenous Australians were almost twice as likely to be obese (27%) compared with 15% of non-Indigenous Australians.3 Many of these chronic lifestyle-related problems have been attributed to changes in lifestyle since European settlement, specifically poor diet and physical inactivity.4,5 In 2002, just over half (51%) of Indigenous Australians aged 15 years had not played sport or participated in any physical activity in the last 12 months, with inactivity rates increasing with age.3 Physical activity has been touted as the best buy for public health.6 Yet, few data exist that describe the physical activity of Australias Indigenous population. Data collected by the Australian Institute of Health and Welfare (AIHW), suggest that Australias Indigenous adults were less likely to be physically

Abstract

Issue addressed: There is evidence that many of the chronic lifestyle-related problems faced by Australias Indigenous population are related to physical inactivity. However, little is known as to how to introduce physical activity programs that will be meaningful, relevant and acceptable to Australias Indigenous people. Methods: Seventeen focus groups involving 96 Indigenous adult participants, explored the meaning of, the barriers to, and potential strategies for promoting physical activity among urban Indigenous Australians. Indigenous researchers moderated the groups and data were transcribed verbatim and analysed independently. Results: The relationship between physical activity and health was well understood by participants. Commonly reported activities undertaken by participants included walking, domestic chores and specific sports. Barriers to activity included being judged by others when in public spaces, cost and accessibility. Family engagement and group-based activities were strong motivators for participation. Conclusions: Attempts to increase physical activity among urban Indigenous Australians must engage the community from the outset, and focus on increased opportunities for family-orientated activities, and/or group walking programs; cost and safety must also be addressed. Key words: physical activity, Aboriginal, Torres Strait Islander, walking
Health Promotion Journal of Australia 2008; 19:102-8

So what?

The findings of this study may be used as a guide towards developing effective physical activity programs for urban Indigenous Australians. Local communities must be involved in developing new family-orientated initiatives so that programs will be meaningful, relevant and acceptable to Australias Indigenous people.

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active in their leisure time than non-Indigenous Australians. AIHW also reported that 40% of the Indigenous participants reported no leisure-time physical activity compared with 34% of non-Indigenous Australians, and that Indigenous women (42%) were more likely to be inactive than Indigenous men (38%).7 Bauman and colleagues (2002) noted that before physical activity can be addressed in this population group a better understanding the physical activity needs of these people must be established.8 In a recent review of physical activity interventions for Australias Indigenous population, Shilton and Brown noted a lack of evidence on which to develop effective physical activity interventions, and a need to fast track research in this area into the scientific literature.9 Interestingly, the literature review conducted to inform this study identified just one study that attempted to understand the social and cultural context of physical activity among urban Indigenous people.10 Thompson and colleagues interviewed 57 urban Indigenous Australians aged between 20 and 50 years living in Melbourne.10 They found that participants conceptualised physical activity in three ways: 1) exercise, as an optional activity, 2) everyday activities, a necessary part of life, and 3) sport for improving ones individual performance. They also reported that physical activity, like food, is positively supported within the context of the family and community, but negatively associated with the promotion of individual physical health.10 That is, Indigenous people rarely participated in activities that only involved themselves, especially when the main aim was to maintain their own health. However, participants did report that they would engage in individualised activity in response to managing acute illness.10 A significant challenge for promoting physical activity to Indigenous Australians is knowing how to develop and implement effective, appropriate and sustainable initiatives. Further, it is important to note that Indigenous Australian groups are not homogenous,11 thus further research is required to identify culturally appropriate ideals that may be drawn upon when developing community specific physical activity programs. The aim of this research was to extend the work of Thompson and colleagues10 to generate a deeper understanding of issues related to physical activity among urban Indigenous Australians living in Brisbane. That is, to specifically explore the meaning of, the barriers to, and potential strategies to promote physical activity participation among urban Indigenous Australians. The findings of this research could then be used to initiate further investigation of factors important to Indigenous peoples physical activity, thus improving the capacity for developing programs that may increase participation among urban Indigenous Australians.

Methods
Qualitative data were collected from members of an urban Indigenous community through a series of focus groups. The group discussions focused on the participants understanding and perception of physical activity, and the types of physical activities they participated in, the barriers limiting their participation and development of potential strategies that could promote, physical activity participation among urban Indigenous communities. Two series of focus groups were conducted, the first between November 2002 and July 2003, while the second between June 2004 and December 2004. This research was approved by The University of Queensland Human Research Ethics Committee (approval number: 2022000867) and by local Indigenous community organisations. The focus groups were facilitated by an Indigenous Health Promotion Officer and an Indigenous research student.

Participant Recruitment
Due to the difficulty in identifying and randomly selecting Aboriginal and Torres Strait Islander people from the population, participants were recruited from organisations and groups that delivered various Indigenous community programs. Permission to recruit participants and conduct the groups was sought from the organisations leaders. Once permission was granted, arrangements were made to talk to the groups that regularly visited the organisations. This helped to identify which of the groups included people that met the inclusion criteria for the study. Eligible participants included those who identified as being an Aboriginal and/or Torres Strait Islander, were aged over 18 years and who lived in the urban community. Prior to data collection, each organisation received a briefing session on the current evidence pertaining to the state of Indigenous health and the importance of the research project. This helped to gain peoples interest and trust. It also helped people to gain a sense that they would be contributing to the evidence to assist in developing programs and resources to specifically meet the needs of urban Indigenous people. Participants were informed that the focus group discussions would be tape-recorded to preserve the accuracy of what was discussed. Participants were then given information sheets and informed consent forms which explained their rights and responsibilities regarding the research. Those interested in participating in the focus groups completed and signed the informed consent forms, and the discussion began.

Focus group procedures

Each focus group began with participants completing a brief demographic questionnaire. They then introduced themselves, and their families origin to the group. The

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formal discussion then began with a broad question about what physical activity meant to them followed by what types of physical activity they did; what made it difficult for them to be physically active; what was the best time for them to do physical activity; and what activities they would like to do more of. Finally, they were asked what would make it easier for them to do more activity. When the discussion group finished, the participants were thanked for their time and reminded that they would be invited to the feedback session upon completion of the study.

Data analysis
Descriptive statistics were calculated from the demographic questionnaire data using SPSS v11. Each focus group discussion was transcribed verbatim and transcripts thematically analysed independently by two researchers. The thematic analysis followed a systematic and iterative process, the cut and paste technique, whereby major themes and categories were identified and used to classify data from each group, then across the complete dataset.12 Each analyst classified the data according to the three main research questions: 1) participants understanding and perception of physical activity, and the types of physical activities they participate in; 2) the barriers limiting their participation; and 3) potential strategies to promote physical activity participation among urban Indigenous Australians. The separate analyses were compared and discrepancies discussed with a third researcher until consensus was reached. Quotes that represent the essence of each theme are presented in the results.

During the second round of data collection, 11 focus groups were conducted with 62 Indigenous people (n=25 males and 37 females). Each group involved between five and 10 people. The majority of participants (n=39) were aged 30-44 years. Only four were aged 45-54 years and 19 were 55 years and over. Most participants identified as being Aboriginal (n=56); six were both Aboriginal and/or Torres Strait Islander. A high proportion of the sample had attended university or a college of advanced education (n=44). The majority of participants (n=36) were either married or in a defacto relationship and the remainder were single (n=20), widowed (n=2) or did not respond (n=4). Many were in full-time employment (n=41); nine were unemployed, eight were employed part-time, two were retired and two did not respond.

Perceptions of and types of physical activity they participate in

When participants were asked what physical activity meant to them, and what types of physical activity they did responses tended to be gender-specific. For example, female participants felt that physical activity doesnt have to be sport or anything its physical, while the males reported that it was sport, doing some sort of sporting activity. The women in the groups viewed physical activity as walking and household chores; as two women said, my exercise is doing my laundry, hanging out clothes, walking up and down that hill, and all our activities are done in the house. While some males identified domestic chores as physical activity, they tended to be chores outside the house that were more vigorous, like raking up the leaves and mowing, chop down tress and chainsaw. The male participants clearly felt physical activity was exercise, any type of physical activity that sort of gets the heart rate up, fitness, weights and/or sport. While sport dominated the discussion among the male participants, some of the female participants also reported participating in sport. Contact sports such as football and boxing dominated the males discussion, while the females focused on non-contact sports such as netball and basketball. Both genders reported playing touch football. Walking also emerged as a common activity for both genders; many participants reported walking as part of their daily schedule, in particular walking for transport. For example, I walk to the train station once a week or getting the kids off to school and then going to pick them up you know until they are big enough to walk home themselves. There was also a large emphasis on the family-orientated activities, especially among the female participants who consistently reported engaging in activities that involved their children. For example, running with the kids, running after the kids, mucking around with the kids in the water.

Feedback session
A feedback session was held at an Indigenous community centre and lunch was provided. The Indigenous researcher gave an overview of the study and explained how the findings could be used to advocate for the development of Indigenous physical activity programs. Participants were again thanked for their time and willingness to assist in the research.

Results
Focus group participants
Six focus groups involving between four and eight participants were conducted during the first round of data collection (total N=34 participants: n=20 males and 14 females). All identified as Indigenous. Nine participants reported they were aged 18-30 years, 16 were aged 31-50 years and eight over 50 years. Most participants reported they had been to high school, three participants had completed year 12, six had a trade/certificate and four had been to university.

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Among the activities mentioned there were also some that the participants reported that they would not do. For example swimming Not many here in Logan go for a swim you know gardening I dont think you find that many young Murris doing gardening or that or cycling because not very many Murri adults got a bike and be riding one.

up some of our kids. We are stressed when we are trying to find some sort of activity for our kids and at the same time we are not looking after number one you know? Other reasons for not participating in more physical activity included perceived affordability. For example, they said, It just costs too much, I am not really into physical activity except around the house. I use what I have there because I cant afford to go outside, and When youre paying for your kids, you cant afford to go out and do anything for yourself. Another barrier to regular physical activity was the perceived lack sustainable local physical activity programs. Some participants reported that many sports were only short-lived, offered as a one-off activity, like carnivals or tournaments: we want to have a little girls netball team a mothers team things like that ongoing, not a one off.

Barriers and challenges to physical activity

When asked what made it difficult for them to be physically active, a number of participants reported that their physical activity patterns had changed as a result of changes to their circumstances (such as having children), and the environment they live in. As one female participant said, It is different like when I was living over at Straddie you know we would walk to the beach, go fishing and things like that and would walk way out, but here, you come here and it is all stopped and we dont do those things now you know. Along similar lines another female participant spoke of moving to an urban setting: you know before living in the city we never had a car we used to walk from one end of the city to the other you know. We used to walk from West End down to the Valley, you know, we wouldnt jump on the bus we would walk. You know times have changed and we got cars now. Many groups made comments about the social environment in which they lived and a feeling of being judged in public spaces as a barrier to getting out and about more. For example, one male participant said, We walk down the street and people are watching us and we dont like that, you know, we are all human beings. Back home we felt safe and we could walk around and no one would worry about us. That is why I dont like street walking because people all of a sudden they are judging me and watching me and thinking: is he going to steal my car or something? That is the perception you get all the time you are walking around. I dont bother walking on the streets. It is the environment we live in and these kids understand that. For the female participants, security and personal safety were also a concern in public spaces. For example, Hey security reasons and you know they are frightened you know the local group that comes down here things like that will stop families and whatever going to where you know and just other people, you know just accessing the parks. For the males one of the main factors stopping them from ongoing participation in sports was injury, illness or disability. For example, I cant jog for long distances because of injuries I got playing competitive rugby league and because of my injury Im not very active now. Many of the female participants highlighted the demands of bringing up small children and explained how this affected their own activity levels: We are strained by trying to bring

Identifying strategies to make being physically active easier

When asked what activities they would like to do more of and what would make it easier for them to do more activity a variety of responses were generated, but group based activities were a popular suggestion, whether it be walking groups, have a group of people they are the ones to motivate you or get a group together to do line dancing sort of stuff. Many participants felt that a key factor for ongoing participation was that the activity should be fun and not feel like a chore. For example, make it fun; I used to play netball and we played because it was fun. Most participants had children, thus many suggestions related to the need to provide opportunities for families to be active together, reflecting the importance of family in Indigenous communities. For example, There are a lot of people out there who do exercise on weekends. We got some strong families around that get together and go and play in the park with the kids and get up and play sports. Another common perspective was that it was important for adults to be active role models for young people, you know, to train the children to teach them how to get active and that, or to do it as a family. However, the cost was again identified as a barrier. One participants quote represents how many felt, they are trying to promote sports but the cost factor involved, people cant afford to get the family involved. Participants again mentioned that there were occasional sports events and teams that they and their family could join. However, many commented that these opportunities did not last and that there was an absence of sustainable family-orientated activities. Local accessibility of opportunities was also identified as an issue to ongoing participation. For example, we want our own stuff instead of going to Brisbane.

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Discussion
As highlighted by Shilton and Brown, despite the powerful rationale for focusing on physical activity in Australias Indigenous communities9 there is little information relating to needs and barriers on which to build programs that will be meaningful, relevant and acceptable to Australias Indigenous people. This study used a series of focus group discussions to provide some insight into urban Indigenous Australians perceptions of physical activity, identified barriers that need to be overcome and potential strategies suitable for promoting physical activity to urban Indigenous Australians. One of the main findings from these focus group discussions was that the relationship between physical activity and health appeared to be well understood. Participants in this study readily identified the benefits of physical activity and appropriate forms consistent with the current guidelines.13 All groups discussed walking, competitive team sports, family-orientated activities and domestic chores as types of activities they did or liked to do. These findings are consistent with those of Thompson and colleagues who reported that Melbourne-based Indigenous people thought about physical activity in three ways: exercise, competitive sports and everyday activities.10 Domestic work appeared to be the predominant daily activity undertaken by the female participants, with many reporting there was little time or energy left for activities of a different nature (e.g. participation in team sports). This finding is consistent with previous research conducted with women from different cultures and backgrounds.14,15 However, a number of the women in the present study also reported netball as an activity they had once participated in and would like to be involved with again (if there was a local competition). Men in the present study reported much domestic-related activity as well, but mostly outside the home such as yard work, mowing, raking leaves, etc. Some men also spoke about walking, but most focused on a desire to play contact sports, like football. Consistent among both genders was the fact that they recognised the benefits of physical activity, and they did not do as much as they wanted to do. This is highlighted by the fact they often spoke in reference to activities that they had once participated in more frequently and would do so again (if given the opportunity locally). Many also made mention of activities that involved some element of competition; the most common examples were rugby league and touch football for males and netball for females. In support of the findings of Thompson et al., family was considered to be extremely important in the context of physical activity.10 Data clearly show that Indigenous Australians

have children earlier than non-Indigenous Australians,16 and that having a family significantly (and negatively) affects the physical activity levels of the parent (and especially the mother).17 Any attempt to increase physical activity among Indigenous Australians should therefore involve strategies that provide opportunities for the whole family. Several other issues were identified as barriers to physical activity participation. For the women, domestic duties and child minding were critical factors influencing their current activity levels. An interesting point is that domestic duties and household chores when done continuously in lab-based studies do require moderate energy expenditure which can be beneficial in terms of health.18 Further acknowledgement and education of the role domestic chores can have in contributing to overall physical activity levels warrants further investigation with Indigenous adults. Perceived neighbourhood safety was also cited as a barrier to participation. While they did not necessarily feel unsafe, many of the men mentioned that they did not walk because they felt they were being judged by others when out in public. Lack of safety also forced a number of parents to keep their children at home. Bauman and colleagues have previously identified child safety and security issues as barriers to increasing physical activity levels,8 and this particular sentiment was shared by the participants in this study. A number of the participants still had an interest in playing sport but mentioned that there were few opportunities in their area; despite the occasional sporting tournament or carnival. Many also felt that that there was a need for ongoing programs or opportunities for community participation in regular sporting activities. Cost was another frequently cited barrier to participation, and this was especially the case for families. If the family could afford to enrol a child in organised sport, there were often little funds left to support parental participation. For population groups and communities on low incomes, cost is a significant barrier to government agencies trying to promote greater activity levels.19 One of the strengths of this study is its relatively large sample (17 groups involving 96 participants). However, the findings are limited by a number of factors, including that all data were collected via self-report methods. Thus, the data may be affected by social desirability bias,20 or in the case of focus group discussions, represent the views of domineering group. However, every precaution was taken to ensure that all participants were given the opportunity to contribute to the discussions. Another potential limitation of focus group research is that the data are open to the interpretation of the moderator/analyst. Further, it is possible that the true meaning of responses may be misinterpreted by a non-Indigenous

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person. This was minimised by having an Indigenous researcher moderate the focus groups, analyse the data and interpret the findings of this study. Finally, participant recruitment was limited to adult urban Indigenous people. This means that the data cannot be generalised to Indigenous people living in rural or remote communities or to urban Indigenous youth. Furthermore, the data should not be considered as truly representative of all urban Indigenous populations as the participants in this study were generally well-educated (most had completed high school, and/or attended university) and were recruited from a metropolitan city. However, one advantage of using local Indigenous programs and organisations as a way to recruit participants is that the top down support from the community/organisational leaders helped potential participants to feel comfortable about volunteering to participate. Collectively, the findings of this study have the potential for local authorities to develop public health initiatives for Indigenous Australians. While there has been an increase in government initiatives in recent years to promote physical activity in Indigenous communities, there remains an absence in the literature of research data necessary to inform effective and sustainable strategies. The priority of the present research was to understand the particular cultural and social issues and work with the community to develop programs that may be driven from within the community by motivated community members. Previous research has found that programs are more likely to be successful if developed and implemented by representatives of the Indigenous community,21-23 so that a sense of community ownership and control can prevail. The findings of this research emphasise that activities that are fun and engage the whole family are very important. As well, mentoring and role modelling are important, to facilitate sustained intergenerational involvement. Walking was identified as a preferred activity in all groups; it has the potential to be a group-based activity (another preference) and is clearly one avenue that should be explored as a way to increase in daily activity levels among urban Indigenous Australians. The findings of this study clearly emphasise the need to shift in focus away from individual activity pursuits, to focus on family and community opportunities. However, before this recommendation may be realised, further research is required to explore issues faced by Indigenous service providers when developing and managing physical activity programs aimed at the local Indigenous population.

Conclusions
The present study has found that Indigenous females identified moderate domestic (household) duties, walking and noncontact sports (such as netball) as physical activity. The male participants generally identified vigorous outdoor domestic chores and contact sports as physical activity. The main barriers to being more active were the feeling that they were being judged by others when in public spaces, cost and accessibility. Family engagement in activity appeared to be a strong motivator for physical activity as were group-based activities. Initiatives aimed at increasing the activity levels of urban Indigenous Australians should involve the community earlyon, and focus on increased opportunities for family-orientated activities, and/or group walking programs.

Acknowledgements
The authors would like to thank the community organisations and groups who assisted in the research and the participants for the time they spent sharing their thoughts with us. Thank you also to the Brisbane Southside Indigenous Public Health Forum who provided feedback and encouragement for the project. This research was partially supported by Queensland Health (Brisbane Southside Public Health Unit) which provided a scholarship to Julian Hunt, and a grant awarded to Dr Marshall from the Commonwealth Department of Health and Ageing.

References
1. Australian Institute of Health and Welfare. Australias Welfare 2005. Canberra (AUST): AIHW; 2005. AIHW Catalogue No.: AUS65. 2. Australian Bureau of Statistics. The Health and Welfare of Australias Aboriginal and Torres Strait Islander Peoples, 2005. Canberra (AUST): ABS; 2005. ABS Catalogue No.: 4704.0. 3. Australian Bureau of Statistics. National Aboriginal and Torres Strait Islander Health Survey 200405. Canberra (AUST): ABS; 2006. ABS Catalogue No.: 4715.0. 4. Reid J. Womens business: cultural factors affecting the use of family planning services in an Aboriginal community. Med J Aust. 1979;1(2):1-4. 5. ODea K. Marked improvement in carbohydrate and lipid metabolism in diabetic Australian Aborigines after temporary reversion to traditional lifestyle. Diabetes. 1984;33:596-603. 6. Morris JN. Exercise in the prevention of coronary heart disease: Todays best buy in public health. Med Sci Sports Exerc. 1994;26(7):807-14. 7. Australian Institute of Health and Welfare [homepage on the Internet]. Canberra (AUST): AIHW; 1995 [cited 2007 July 5]. Aboriginal and Torres Strait Islander Peoples. Available from: http://www.aihw.gov.au/publications/cvd/hsvd01/ hsvd01-c06.pdf 8. Bauman A, Bellew B, Brown W, Owen N. Getting Australia Active: Towards Better Practice for the Promotion of Physical Activity. Melbourne (AUST): National Public Health Partnership; 2002. 9. Shilton TR, Brown W. Physical Activity among Aboriginal and Torres Strait Islander people and communities. J Sci Med Sport. 2004;7 Suppl 1;39-42. 10. Thompson S, Gifford S, Thorpe L. The social and cultural context of risk prevention: food and physical activity in urban Aboriginal community. Health Educ Behav. 2000;27(6):725-43. 11. Maher P A review of traditional Aboriginal Health beliefs. Aust J Rural Health. . 1999;7(4):229-36. 12. Stewart D, Shamdasani P Focus Groups: Theory and Practice. Thousand Oaks . (CA): Sage Publications; 1990.

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13. Commonwealth Department of Health and Aged Care. National Physical Activity Guidelines for Australians. Canberra (AUST): AGPS; 1999. 14. Kriska A. Ethnic and cultural issues in assessing physical activity. Res Q Exerc Sport. 2000;71(2):47-53. 15. Sternfeld B, Ainsworth BE, Quesenberry CP Physical activity patterns in a diverse . population of women. Prev Med. 1999;28:313-23. 16. Brown W, Ringuet C, Trost S, Jenkins D. Measurement of energy expenditure of daily tasks among mothers of young children. J Sci Med Sport. 2001;4(4):37985. 17. Withers RT, Brooks AG, Gunn SM, Gore CJ, Owen N, Booth ML, et al. Determining energy expenditure during some household and garden tasks. Med Sci Sports Exerc. 2002;34(5):895-902. 18. National Centre for Health Promotion. Health Behaviour in Secondary School Students, NSW 1998. Sydney (AUST): NCHP University of Sydney; 1998. , 19. Nancarrow C, Brace I. Saying the right thing: coping with social desirability bias in marketing research. Bristol Business School Teaching and Research Review [Bristol Business School homepage on the Internet]. 2000; [cited 2007 July 5]; Issue 3. Available from: http://www.uwe.ac.uk/bbs/trr/Issue3/Is3-2_2.htm 20. Australian Bureau of Statistics. Aboriginal Statistics. Canberra (AUST): ABS; 1986. 21. Rowley K, Best J, Mc Dermott R, Green E, Piers L, O Dea K. Insulin resistance syndrome in Australian Aboriginal people. Clin Exp Pharmacol Physiol. 1997;24(9-10):776-81. 22. ODea K. Westernisation, insulin resistance and diabetes in Australian Aborigines. Med J Aust. 1991;155:258-64. 23. Parker EP Meiklejohn B, Patterson C, Edwards K, Preece C, Shuter P et al. , , Our games our health: a cultural assert for [promoting health in Indigenous communities. Health Promot J Austr. 2006;17(2):103-8.

Authors

Julian Hunt, School of Human Movement Studies, University of Queensland Alison L. Marshall, School of Public Health, Queensland University of Technology David Jenkins, School of Human Movement Studies, University of Queensland
Correspondence

Dr Alison L. Marshall, Queensland University of Technology, School of Public Health, Victoria Park Rd, Kelvin Grove, Queensland 4059. Fax: (07) 313 83369; e-mail: alison.marshall@qut.edu.au

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