This is one of the first mixed method process evaluations embedded with a pragmatic controlled fitness trials in an Indigenous population to examine the barriers to participation of high and low attendees. Despite sharing positive motivations and positive program experiences with high attendees, those who struggled to attend classes either experienced several competing obligations and logistical issues that made attending very difficult in the absence of instrumental support, or they had a major event occur, such as a death in the family. In particular, low attendees experienced more competing family obligations and work obligations.
There were similarities in the stories shared by the women in the positivity of their program experience and program motivations. The motivations of the women to enrol in the program, and to continue attending the program, were also similar and there did not appear to be a discrepancy between the two groups. Participants reported enrolling in the program primarily for the perceived health benefits. Participants perceived the program to be of high quality and all but one only had positive things to say about their program experience. Participants felt comfortable and reported a positive program atmosphere. The fact that the program was designed by an Indigenous woman, for Indigenous women, and was implemented in a culturally safe environment contributed to the women’s positive program experience.
A review of the literature did not reveal any qualitative studies on the barriers to participation of Indigenous women engaged in equivalent structured group-based lifestyle intervention. However, previous studies on at-risk minority populations report similar findings. The community health assessment and promotion project (CHAPP) was a ten-week group-based exercise and nutrition intervention in an urban setting, which provided crèche and transportation. All participants were obese Black-American women. CHAPP staff followed up non-attendees and documented their self-reported reasons for non-attendance. Similar to our study, the most common reasons related to competing obligations (family and work) and personal illness. Likewise, a centre-based program for physical activity among low-income, Black-American families with young children found that competing obligations (work and school) were the primary reason for non-attendance.
In another study, focus groups amongst African-American women on the perceptions of physical activity and personal barriers and enablers found that lack of time, lack of self-motivation and competing priorities (putting their family first) as the most frequently cited perceived barriers. A qualitative inquiry into the barriers and potential strategies for promoting physical activity among urban Indigenous Australians using focus groups also found that competing family obligations (such as raising children) was a barrier to being active. Participants also identified personal illness and injury, the perceived financial cost and the lack of sustainable programs as barriers.
The role of competing family obligations cannot be under-estimated. With 40 per cent of Aboriginal and Torres Strait Islander Australians under the age of 15 and with a higher number of children per household, compared with non-Indigenous women, Aboriginal and Torres Strait Islander women have considerable family responsibilities, not to mention cultural obligations. It is of interest to note, however, that low attendees had fewer dependents under the age of 18 than high attendees. Our interviews suggest that the presence of instrumental support for high attendees and absence of such support for low attendees can be attributed to non-attendance in the face of logistical issues and competing obligations. Like these other studies, the program was implemented in an urban setting, and some of the women were commuting between home and work. These factors may be less important in rural and remote settings where travel and parking may be more convenient and instrumental supports may be closer to home.
An older, comprehensive, review of physical activity determinants found that self-motivation, support from a spouse and reinforcement from program staff and or activity partner influenced adherence. Self-motivation was a stronger enabler for high attendees than it was for low attendees, and the presence of instrumental support was a key factor in offsetting participant’s competing obligations at home and work. They also found that perceived convenience or distance to travel can predict participation as can a perceived lack of time. Similar to our study, they noted that an interruption in usual routine, such as a major life event, can interrupt or discontinue participation even in the most motivated and well-intentioned participant. Dishman et al. also found that strategies that effect change, all have a common dimension of social reinforcement and appear more successful when conducted in groups.
The collective process of data analysis and interpretation challenged the researchers to reflect critically on their personal biases and how these biases were reflected in their interpretations of the data.The first author is a Torres Strait Islander woman with strong connections to family and community and expertise in exercise physiology and in the design and management of health promotion programs. Even though she is not originally from the community where the program was implemented, her life and work experiences contributed to the cultural understanding and insight used to interpret the women’s stories. As the designer and evaluator of the program, she attended most exercise classes, was abreast of the day-to-day running of the project and all communications with participants. During the course of the project she built strong relationships with most of the participants and came to know the circumstances affecting their lives. This knowledge deepened her insights into the data.
The findings of this study have implications for the design and delivery of group-based exercise programs targeting Indigenous women living in urban areas. Based on our findings, there may be some benefit to implementing pre-program workshops with participants to identify potential barriers and solutions to their program attendance. We found, for example, that it was important to provide instrumental supports like crèche and transport to enable some women to attend the exercise classes. Having a process that identifies and addresses the barriers emerged is important. It is additionally important that the program invest resources to develop a professional program that offers consistent training, technical support and feedback to staff responsible for implementing the program. Offering a well-organised program, run by qualified, supportive and motivating staff contributes to a positive and engaging atmosphere for participants. We also found that running the program only for Aboriginal and Torres Strait women, in a non-gym setting, created a comfortable place for women to exercise and positively influenced their motivation to attend.
The study findings should be interpreted in light of the following two limitations. First, the study is based on a small number of interviews from participants who completed the program and consented to an interview. Interviews from participants who withdrew from the program or were lost to follow-up would likely have provided greater insight into the factors influencing participation. Consequently, the circumstances and barriers affecting the participants that were not interviewed are unknown. Second, although the semi-structured interview was designed to capture participant’s barriers and enablers to attendance in relation to their life circumstances, how they came to enrol in the program and what motivated them to continue attending, the interview guide probed into other issues as well, and this may have detracted from the richness of the women’s stories about their engagement.