Merne Mwerre Artweye Areye-ke Program: Implementation & Evaluation of a Childhood Diabetes Prevention Program in Remote Australia – adapted Tribal Turning Point

Implementation The 10-week intervention program will involve the following: I. Adapted Tribal Turning Point curriculum delivered in a group setting to Aboriginal children and caregivers (Active Learning Group Classes), II. Individual motivational interviewing (MI) sessions for child/caregiver pairs, and III. A toolbox of individual and community-specific resources (adapted from Tribal Turning Point). The first 6 months of the program is of higher intensity (Intervention Core). Numbers of classes, Motivational Interviewing (MI) sessions, boosters delivered is outlined below. Months 1-6 Intervention Core 10 Active Learning group classes 4 caregiver/child motivational interview sessions Months 7-12 Intervention Booster 2 Active Learning group classes 3 caregiver/child motivational interview sessions Intervention Toolbox: available as needed/recommended by coaches/staff (details below) Active (Intervention) learning group classes Group classes are made up of a maximum of 10-15 children and their parent/carer, they run for 2 hours, held every 1-2 weeks during school term, at a time recommended by the community (explored during community engagement prior to start of intervention). Classes are attended by children and their parent/caregiver together and include activities. Each class is offered on 2 days of the week to provide flexibility (including last minute changes). Diabetes prevention strategies are incorporated in classes through physical activity (at least 45 minutes, open re type, moderate-to-vigorous for example: a game of basketball, traditional dance or an activity determined by the community group - physical activity will be assessed using self-reported Adolescent Physical Activity questionnaire), interactive learning, incorporation of culture and a group healthy meal. Daily targets are promoted using “2-5-2-1-0” messaging: 2 servings of fruit, 5 vegetables, less than 2 hours screen time, greater than and equal to 1-hour physical activity and 0 servings of sugar-containing beverages or confectionery. Children and parents identify a specific, attainable goal to be achieved before the next session, and make an action plan to achieve the goal. Self-monitoring trackers are used to highlight successes and assist discussion of problem-solving strategies. To promote engagement, incentives are earned for attending classes, submitting goal-tracker forms, attending events, later redeemed for prizes (sport equipment). The Tribal Turning Point curriculum was extensively revised during our formative work, with considerable input from local NT clinicians (dietitians, exercise physiologists, Aboriginal Health Practitioners, health promotion team members, diabetes educators and others) and community members. The sessions of the revised curriculum are outlined below. Merne Mwerre Artweye Areye-ke (adapted Tribal Turning Point) curriculum Sessions 1 Welcome, awareness 2 Traditional food 3 Choosing healthy food 4 Mindful eating 5 Joyful movements 6 Balancing plate 7 Healthy environment 8 Eating out 9 Helpful thoughts 10 Stay motivated Individual motivational interviewing sessions Motivational interviews with parent-carer/child pairs are performed by trained Aboriginal health facilitators (trained in Year 1) exploring health and behaviour goals. Sessions (1 hour each) are performed in a location of the participant’s choice. Four principles of motivational interviewing guide the sessions: express empathy, develop discrepancy, roll with resistance, and support self-efficacy. Consultants experienced in providing motivational interviewing will be employed to deliver motivational interviewing sessions to participants, and to train and support Aboriginal Community Controlled Organisation Health staff in delivering these sessions. The TTP toolbox The toolbox addresses domains of the socio-ecological model of health behaviour, aligning with Aboriginal and Torres Strait Islander wellness models: individual, home/family, school, community, and health systems. Locally developed resources such as the storyboard of the intergenerational chronic disease story (developed by NT Health Aboriginal staff), will be incorporated where appropriate, and the toolbox used to facilitate program intention for each participant. Toolbox resource examples across domains are (i) individual level: communication strategies (phone reminders, buddy system), recipes, meal plans; (ii) family: home food and activity environment review; (iii) school: facilitate participation in school physical activity and facilitate choosing healthy food; (iv) community: facilitate programs regarding healthy habits and group support; (v) health system: facilitate health appointments. The resources that are used during the sessions will be facilitated by the Aboriginal Community Controlled Health Organisation Staff supported by Menzies Research Staff. The intervention toolbox resources will be available as needed, or as recommended by coaches/staff and or at the request of families during the intervention core and booster period. For example, handouts to support healthy diet and or physical activity will be available to participants and their families during and after sessions. The assessment and monitoring of adherence to the intervention will be undertaken through ongoing evaluation at different timepoints (pre, during and post intervention) to understand the factors related to participant engagement (recorded reflective notes post sessions-use of resources), attendance (attendance tracking logs), program delivery and potential for sustained delivery. An evaluation of the adapted Tribal Turning Point program involves a mixed-methods outcomes and process evaluation, guided by the REAIM (reach, effectiveness, adoption, implementation and maintenance)/PRISM (practical, robust implementation and sustainability model) framework using principles of the Lowitja Institute Evaluation Framework. Methods for exploring program adaptation and appropriate implementation will include surveys, reflective notes, interviews and focus groups with evaluation participants" and "We will conduct formal, recorded, individual research interviews with a sample of program participants at each community. Study staff trained in qualitative research will conduct the interviews at each site, either in person or by phone, depending on participant preference. Parent/caregiver and child/ren (combined) interviews will occur at 12 months, and 24 months (for trial/intervention sites). We will randomly select up to 10 parent/caregiver and child/ren per community, resulting in up to 60 parent/caregivers and child/ren interviews at 12 months and 30 at 24 months. Because we are interested in the motivations, experiences, and perspectives of intervention and control participants, we will aim to interview parent/caregivers from both groups. Interview questions will explore the parent/caregiver’s experience in the program, the results they achieved, the challenges they faced, their confidence to maintain lifestyle changes long-term and for those interviewed at 24 months, what if any lifestyle changes have been maintained and how this has been achieved. We will also interview stakeholders from the community including program facilitators, at the end of the program (12 months) and after 24 months in the trial/intervention communities. We will interview approximately 5 stakeholders from each community, resulting in up to 30 interviews at the 12 month point and 15 at 24 months. Questions will explore factors including: the challenges and successes to enrolling participants in the program, keeping participants engaged, delivering the intervention as planned, how the program fits within the communities’ goals, priorities, and resources, awareness of diabetes risk in youth, community level factors that may have influenced implementation and effectiveness of the program, how challenges were addressed during the program, and the barriers/facilitators to continued program delivery in each community. The focus of questions at 24 months will be maintenance of program components and other supporting initiatives that may have developed in the community or any significant changes that have been witnessed in relation to the program delivery.