Introduction
Methods
Research partners
Interventions
Element | Cohort 1 | Cohort 2 |
---|---|---|
Physical Activity | Four self-selected activity groups: a) walking group + box fit (moderate intensity) or Zuu fit (high intensity interval training) classes; b) walking group only; c) Box and/or Zuu fit classes; and d) self-organising group involving various activities including walking and touch rugby | Individually tailored consultations about physical activity (education, workout plans, and physical activity sessions); Delivered through whatever means was desired (e.g., phone, face-to-face, home visit) |
Nutrition | Weekly one-hour didactic session | Weekly 30-min education delivered via a booklet |
Who Delivered | Tuakana (senior mentor) who was also a participant | Kaiarahi (guide or community health worker) |
Frequency | Three times per week for 1 h each session | Determined by the participant |
Other Elements | Monthly prizes for greatest percentages of weight loss; Facebook group; Participant information booklets | Health screen with nurse (e.g., lipids, blood pressure, CVD risk) at baseline with referral to GPs if necessary |
Research design
Data collection
Measure | Baseline | Post-Intervention |
---|---|---|
Height & Weight (BMI) | X | X |
Self-reported health (1 item) [33] | X | X |
X | X | |
Health service utilisation (6 items) [36] | X | X |
Total days with 30 min moderate/15 min vigorous activity (1 item) [36] | X | X |
Nutritional intake (9 items) [37] | X | X |
Social support (2 items) [38] | X | X (cohort 1 only) |
Readiness to change (3 items) [39] | X | X (cohort 1 only) |
Self-efficacy to change (3 items) [39] | X | X (cohort 1 only) |
New Zealand deprivation index (8 items) [40] | X | |
Trust in institutions (7 items) [41] | X | |
Cultural identity (2 items) [42] | X | |
Demographics | X | |
Open-ended questions: impact on health and that of their whānau, changes made and what they liked about the programme | X |
Data analysis
Results
Co-design process
Event | Date | Description |
---|---|---|
Initial scoping of project | 1–6/2016 | Held several meetings to build a relationship between the university team and Poutiri. We also identified shared goals and what work had been done in the community previously and needs for further information. Poutiri identified the importance of sustainability for any new intervention. |
Developed HPW Implementation Framework [28] | 2–9/2016 | Reviewed the international literature and shared framework with stakeholders for feedback. |
Created causal loop model | 6–12/2016 | Created a causal loop model of factors for prediabetes and diabetes following soft systems logic using stakeholder interviews; Prediabetes was the primary disease of interest initially. |
Conducted patient interviews | 6–12/2016 | Poutiri conducted interviews of their own patients with pre-diabetes and diabetes to better understand facilitators and barriers to care [46]. |
Meetings with key Poutiri stakeholders | 3–6/2017 | Met with Poutiri Board of Trustees, Poutiri’s network or providers and the District Health Board to share findings from the previous year’s work and to further scope intervention and identify additional stakeholders. |
Initial co-design meetings | 7–8/2017 | Held several co-design meetings following a design thinking framework to determine target audience, craft potential interventions and identify partners. Information from systems map and patient interviews was shared and integrated into interventions ideas. Stakeholders including representatives from two primary health organisations (PHO), a public health organisation, and Poutiri’s network of providers. |
Advanced co-design meetings | 8/2017–3/2018 | Determined the key target population for these stakeholders should be Māori men because there were no existing contracts that targeted men; focus on pre-diabetes and related conditions particularly related to weight. We honed in on gang members and their whānau because they represented a group underutilising health services and were a group several stakeholder organisations wanted to reach. We held co-design meetings with men and their whānau led by Poutiri. Other key stakeholders were a social service organisation for gang members, a PHO, and a provider in Poutiri’s network. |
Launch intervention | 5/2018 | Held a health fair and began recruitment for a lifestyle intervention with integrated care (i.e., nurse to triage health issues and refer to needed services; community health worker to provide lifestyle intervention and be a navigator; social services; activities for community health improvement all through a single place of contact). Unfortunately, it never gained traction. The PHO had originally committed 1 day a week of nurse’s time along with co-delivering the lifestyle intervention and collecting data from a different community as a comparison group. Unfortunately, they had to withdraw their full support, and re-commit their resources to more pressing priorities due to losing a significant proportion of their primary health practices and patients to another PHO. Additionally, the social service provider had internal governance challenges that required immediate attention, which meant they could no longer support the intervention in terms of co-delivery and access to the target population. |
Re-design intervention for 1st cohort | 8–9/2018 | With an emphasis on research team flexibility to address changing conditions, we focussed on re-designing the intervention with Poutiri as the only community stakeholder. Community members had some input into a lifestyle intervention for men and their whānau. The focus became solely on the lifestyle intervention rather than integrated care due to time constraints. The cohort focused on physical activity with some nutritional information. |
Implement intervention | 9–12/2018 | Intervention was implemented with the first cohort. |
Re-design intervention for 2nd cohort | 1–3/2019 | The first cohort had a limited number of men so we redesigned the intervention with direct input from the target audience. The result was an individually-tailored intervention to allow for flexibility for full-time working men. |
Implement intervention | 3–6/2019 | Intervention was implemented with the second cohort. |
I think we did – well, certainly in committee engagement and cultured centredness we did really well. At the beginning, I think we did four out of five principles really well. I think it’s always been Kaupapa Maori focused. As I said, I think we could have done better in terms of IKT [integrated knowledge translation]. I think we did pretty well systems thinking, but those are the areas that we could have improved. I think we were spot on in terms of community engagement and culture centredness.
Yeah, the model of co-design. Having that framework also sets really strong measures. It’s a proper framework that you can actually measure against [i.e., clear standards for evaluating the quality of co-design]. You don’t have to do a lot of extra mahi (work) to figure out whether what you’re doing aligns with it.
What we did initially with the group down there was amazing. If that would have got off the ground it would have got huge traction and that was no fault of anyone; it was again the environment at the time. But I think that approach and how you guys [academic researchers] approached it in accordance with your framework, perfect. Those other factors that made it tip over were out of our control.
The flexibility [is a strength]. I think organisationally, we needed to be more flexible … The bureaucracy. Yeah, like [other community organisations], we all needed to be a little more flexi. I think you guys were really flexi and made it work.
I don’t think that anything that happened could have been planned for at the start; they were learnings that we had to have. But in terms of what it could have been, we were just talking about how we could have maintained better lines of communication, because as a community partner, we went through changes internally in the role. As a community researcher, I stepped right back out of the role once the new person went in and that meant that there was a loss of that knowledge and oversight … .so, our internal communication could have been better.
In terms of the actual intervention, heaps of learnings, heaps of learnings for us. We went big knowing that we’ll either go big or go home and we’ve had to go home a little bit, but that hasn’t dissuaded us from doing it.
Cohort 1
Demographics
Variable | Cronbach’s alpha | n | M | SD |
---|---|---|---|---|
Age | 8 | 37.62 | 17.25 | |
NZDepi (8 items; 0–8 with 8 being highest deprivation) | 6 | 2.83 | 2.48 | |
Food Insecurity (3 items, 1–3 with 3 being lowest insecurity) | .73 | 7 | 2.48 | 0.50 |
Trust in Institutions (7 items; 0–10 with 10 as highest trust) | .91 | 6 | 4.88 | 2.19 |
Cultural identity (2 items; 1–4 with 4 being highest identity) | .69 | 6 | 2.83 | 0.61 |
Outcome measures
Outcome | Cronbach’s alpha | n | Pre | Post | |||
---|---|---|---|---|---|---|---|
Pre | Post | M | SD | M | SD | ||
Weight (kg) at 12 weeks | 6 | 126.16 | 20.04 | 121.34 | 19.93 | ||
BMI at 12 weeks | 6 | 39.85 | 5.37 | 38.36 | 5.69 | ||
Self-rated health (100-point scale with 100 as highest) | 6 | 56.67 | 29.44 | 70.00 | 24.49 | ||
HRQOL (100-point scale) | .83 | .87 | 5 | 63.57 | 15.26 | 72.43 | 20.50 |
Health service utilisation (6 items; 0–6 with 6 as highest utilisation) | 3 | 2.00 | 2.0 | 2.33 | 3.21 | ||
Total days with 30 min moderate/15 min vigorous | 2 | 4.00 | 0.00 | 3.50 | 2.21 | ||
Nutrition (9 items; 1–6 with 1 = highest nutrition) | .83 | .83 | 4 | 3.44 | 0.45 | 3.17 | 0.90 |
Social support (2 items; 1–5 with 1 = highest support) | .89 | .93 | 5 | 1.60 | 0.55 | 1.50 | 0.50 |
Readiness to change (3 items; 1–5 with 1 = highest commitment to change) | .69 | .88 | 3 | 1.78 | 0.38 | 1.56 | 0.38 |
Efficacy to change (3 items; 1–5 with 1 = highest efficacy) | .79 | .66 | 3 | 1.78 | 0.19 | 1.56 | 0.51 |
Post-intervention open-ended results
Positive Impacts for Individuals | Positive Impacts for Whānau | Why It Worked |
---|---|---|
Involved in oranga tinana activities now [programme to improve health] | Group activities; healthy eating (most of the time) | Eating healthier and exercise |
I now exercise everyday | Everyone in my household are getting into their exercise | One big whānau trying to lose weight. |
Awesome and good outcomes | Whānau are pretty happy | Loved everything and the most effective was the daily exercise |
Cohort 2
Demographics
Variable | Cronbach’s alpha | n | M | SD |
---|---|---|---|---|
Age | 24 | 40.58 | 7.67 | |
NZDepi (8 items; 0–8 with 8 being highest deprivation) | – | 8 | 1.88 | 1.36 |
Food Insecurity (3 items, 1–3 with 3 being lowest insecurity) | .89 | 24 | 2.50 | 0.67 |
Trust in Institutions (7 items; 0–10 with 10 as highest trust) | .93 | 22 | 3.35 | 2.13 |
Cultural identity (3 items; 1–4 with 4 being highest identity) | .69 | 18 | 3.11 | 0.60 |
Efficacy in making change (1–5 with 1 = highest efficacy) | .91 | 24 | 1.61 | 0.75 |
Readiness to make change (1–5 with 1 = highest readiness) | .90 | 9 | 1.74 | 0.72 |
Outcome measures
Outcome | Cronbach’s alpha | N | Pre | Post | |||
---|---|---|---|---|---|---|---|
Pre | Post | M | SD | M | SD | ||
Weight (kg) at 12 weeks | 24 | 123.63 | 22.74 | **117.79 | 20.06 | ||
BMI at 12 weeks | 24 | 37.94 | 7.02 | **36.15 | 6.18 | ||
Self-rated health (100-point scale with 100 as highest) | 8 | 32.50 | 18.32 | **80.00 | 15.11 | ||
HRQOL (100-point scale) | .92 | .83 | 8 | 61.52 | 19.33 | **96.07 | 7.01 |
Total days with 30 min moderate/15 min vigorous | 8 | 3.13 | 3.18 | 4.13 | 1.55 | ||
Nutrition (9 items; 1–6 with 1 = highest nutrition) | .66 | 89 | 4 | 3.42 | 0.44 | 2.33 | 0.92 |
Post-intervention open-ended results
Positive Impacts for Individuals | Positive Impacts for Whānau | Why It Worked |
---|---|---|
My breathing is a lot better. I sleep better and don’t snore as much. | They are happy I’m getting healthy. They are getting healthy too. We eat better and the kids are playing outside more. I think we are happier. | Knowing I was getting weighed and measured by the nurse. She had good information. |
I feel way better and have more energy. I’m eating less rubbish. I feel fitter. | My whānau are proud that I’m making good changes and they awhi (support) me and I awhi them. They are doing good. I think we are healthier and talking more. | The nurse giving information about food and how she spoke to me. |
I eat healthier kai (food). Less fat and sugar. I am feeling healthier | We eat better as a whānau. Eat more veggies and drink more water. My Mrs. loves it. | Someone there watching me and helping |
Don’t get as shy like I used to. | Me and my whānau talk and get out more. The kids are playing outside heaps more now. We just talk about kai (food) now and how I want us to be eating better kai and doing more things without phones and computers. | Talking with us all the time. |