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A new systematic review finds tailored, culturally appropriate programs are the key to better outcomes, and Australia needs more of these programs to prevent and manage type 2 diabetes among Indigenous youth.
A study by researchers at the UQ’s Poche Centre for Indigenous Health has revealed a need for culturally tailored programs to combat the rising prevalence of type 2 diabetes among Indigenous youth.
Dr Edmund Wedam Kanmiki and Professor Abdullah A Mamun led a systematic review of twenty-five studies from the United States, Canada, and New Zealand and Australia, involving 4594 young Indigenous people. The study showed that culturally engaged programs are more effective, and that many more are needed to tackle the prevalence of type 2 diabetes in Indigenous communities.
“Type 2 diabetes is a major public health challenge, affecting over 5% of the Australian population, a significant increase from 3% in 2001,” said Dr Kanmiki.
“Currently about 1.3 million Australians are living with type 2 diabetes,” he said.
“The challenge is that when early onset of diabetes occurs, it tends to increase the risk of several other diseases, reduces the person’s quality of life, and increases cost of care,” said Dr Kanmiki.
“Unfortunately, this occurs disproportionately within Indigenous communities. First Nations children and young adults are more likely to develop type 2 diabetes much earlier in life than their non-Indigenous counterparts, and the incidence is rising,” he said.
Type 2 diabetes reduces life expectancy, but also impacts on a person’s quality of life and productivity, placing considerable strain on health system resources.
“Unfortunately, we don’t have specific numbers for the youth. The data is not segregated. But records from Menzies School of Health Research indicate that Indigenous youth are about 20 times more likely to have type 2 diabetes. So, this is really a problem,” he said.
“Our goal is to contribute to addressing the health inequalities between Indigenous and non-Indigenous populations by focusing on the prevention and management of type 2 diabetes,” said Dr Kanmiki.
Professor Mamun said that the review aimed to identify effective solutions and develop resources to support tackling critical health disparities in non-communicable diseases, including type 2 diabetes, for Indigenous populations.
“We wanted to create a resource program that would really help solve these problems through genuine engagement with these communities,” said Prof. Mamun.
Not enough data for type 2 diabetes, youth
The review found that there were not many studies looking at culturally tailored programs in Australia. Most of the studies in the review (80%) originated in North America, often involving small sample sizes (< 100) and short durations.
“We found only three studies within the Australian context focused on preventing and managing type 2 diabetes among Indigenous children and youth, and they all had less than 100 study participants,” said Dr Kanmiki.
Professor Mamun said that he was not surprised about the lack of studies available.
“Type 2 diabetes was traditionally seen as an adult disease, not a children or youth issue. But now the disease is happening more and more among the younger generations. Our data systems are lagging behind the reality of an increasing prevalence in younger generations. We simply don’t have accurate figures on how many young people or young kids have type 2 diabetes,” said Prof. Mamun.
Culturally tailored programs: key elements for success
Professor Mamun said that among other findings, the review found that programs that used multiple strategies to improve knowledge and promote physical exercise, both within schools and the wider community, were the most effective.
“Most importantly, the key to success was applying culturally appropriate methods to engage children, like using Indigenous foods and games in the teaching and learning process,” said Professor Mamun.
“Engaging community Elders and leaders also helped improve children’s knowledge of their culture and how it supports the science behind healthy living,” he said.
“When we are really engaging with communities, and especially the Indigenous Elders, for example, or even children and adolescents, if they are engaged from the study design phase, from the beginning to the end, the evaluation and all this, then these are the studies that are probably more successful,” said Prof. Mamun.
What is genuine cultural engagement?
Dr Kanmiki emphasised that effective programs prioritise deep engagement with Indigenous culture and community on many levels.
“What we found was that the programs that actively incorporate community input throughout their development and implementation are significantly more successful compared to those that didn’t,” he said.
“Culturally appropriate means rolling out a program with sensitivity, respecting community values and aspirations and collaborating to achieve positive health outcomes,” said Dr Kanmiki.
“You need to prioritise the community’s inputs in the design, the implementation, and even in the evaluation process. You want to avoid assumptions and tailor the content – the materials and the strategy – using cultural materials, like songs, like storytelling, like paintings, like foods, like games, so that the community can identify with the program. Then you have to be respectful in your language,” he said.
“You want to be inclusive and avoid stereotypes. Consider your verbal communication and your gestures, as well. Communities look at these things and it speaks volumes to them. So many things come into play, and these are just some of them,” said Dr Kanmiki.
“Also, key in this context is to acknowledge the historical effects of colonisation, and how that has impacted the community and continues to impact them. This is very important. Once the community sees that you come from that angle, it really gets them to want to buy in,” said Dr Kanmiki.
“The important thing to note is that every community’s culture is different. So, what works for one Indigenous community may not work for the next. So, you always have to be specific to the community,” he said.
Longer programs produce better results
Dr Kanmiki said that there were better results to be found in studies that were conducted over a longer period, creating more and better change.
“The nature of the disease progression, for type 2 diabetes; it’s not something that happens in a short period of time. So, any intervention implemented with a short period can’t really expect any good outcomes,” said Prof. Mamun.
“But that’s what’s happening. We see that most of the studies have been done in probably up to six months, which is really short to see any good outcome,” he said.
“We found that programs that were implemented over relatively longer periods were more successful. Instead of something that’s implemented over something like a few weeks and then you get out,” he said.
“You need to improve the knowledge of the people about diabetes, then you need to improve the change in behaviors. And when that is done, then you want to find out whether this has a sustainable impact on the biomarkers.”
“Community is willing to change their poor health behaviour if there is a culturally respectful support. We see there are some positive changes in terms of health behaviors, for example. But if we want to see the change in biomarker such as sugar levels, etc., it takes longer,” said Prof. Mamun.
Dr Mamun also said that programs need to be run in larger populations, for the results to be more meaningful.
Looking to the future
Dr Kanmiki and Prof. Mamun hope to find partners to work with on future studies.
“But by publishing this paper, we also hope that other researchers and other health services will look at the lessons and use them to inform service delivery to help reduce type 2 diabetes among Indigenous youth in Australia,” said Prof. Mamun.
“We would also like to design a study engaging multiple communities, Indigenous communities, Elders as well as Aboriginal community-controlled health service centres, so we can conduct something on a larger scale. So that we can measure some impact,” he said.
“So, we are actively interested in community health service providers who want to co-design strategies.
Professor Mamun said that with the enormity of type 2 diabetes in Indigenous peoples in Australia, more implementation and community-led research is needed.
“We need to see more implementation of multilevel interventions, which involve communities, stakeholders and Aboriginal community-controlled health services and measure clinical outcomes.”