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The partnership involved a university research team and a Māori community health provider. They engaged with other stakeholders and several cohorts of Māori men through a co-design process to adapt a 12-week lifestyle intervention. The co-design process was documented through meeting notes and interviews with partners. Two cohorts participated in separate single group pre-intervention/post-intervention designs with multi-method data collection. Key outcome measures included weight loss, self-reported health, physical activity, and nutrition. Post-intervention data collection included qualitative data.
Māori men have similar rates of inequities for diabetes and cardiovascular diseases as the larger population statistics [7] that result, in part from challenges to engaging in lifestyle changes and lifestyle interventions due to commitments to family and other priorities along with social determinants and environmental factors [8, 9]. There is ample evidence from systematic reviews that lifestyle interventions involving physical activity and nutrition components are effective at preventing diabetes and cardiovascular disease along with reducing weight [10,11,12,13,14,15]. However, evidence-based interventions may not be effective in Indigenous communities without adapting the intervention to fit the target community; for example, a lifestyle intervention for Māori failed to recruit and sustain participants [16].
An oft-used approach for adapting evidence-based lifestyle interventions is a participatory approach such as community-based participatory research (CBPR) [17]. CBPR is an approach that equitably involves community and academic researchers in all phases of the research [18]. Using CBPR methods, there are numerous studies that demonstrate the effectiveness of culturally adapted and/or created lifestyle interventions on risk factors for diabetes, cardiovascular disease, and obesity for Indigenous communities in general [19,20,21,22,23,24] and Māori communities in particular [25,26,27].
The purpose of this study is to present a case about a partnership involving a Māori community health provider to develop a 12-week lifestyle intervention using the HPW co-design/participatory research process. We hoped to demonstrate the usefulness of the HPW framework for developing a culturally-adapted intervention to fit the needs of the participants and communities. There were two research aims:
There were two cohorts with slightly different approaches that resulted from the co-design process; both targeted Māori men at risk for Type 2 diabetes and related conditions including cardiovascular disease and obesity. Both interventions used components from various lifestyle interventions (physical activity and nutrition) primarily the Diabetes Prevention Program [29, 30]. Other elements of the intervention were developed through the co-design process although one key element (use of a peer or community health worker for support) has grounding in the extant literature [31, 32]. These elements identified during the co-design process came from the participants as being motivating factors for their participation; differences between the two cohorts reflect this process.
The purpose of this study was to present a case of a partnership involving a Māori community health provider and a university research team to develop a 12-week lifestyle intervention through the HPW co-design/participatory research process. This study documented the co-design process and presented findings about two pilot study interventions which approached a clinically significant weight loss of 5% [48]. This section explores these findings in the context of the extant literature and identifies key lessons learnt that may be useful for consideration by other projects targeting health gains in Māori and other Indigenous communities.
The findings of the intervention has some consistency with previous work demonstrating the positive impacts of culturally adapting evidence-based lifestyle interventions [49, 50]. The current intervention used cultural elements and foundations such as tuakana/kaiarahi and whānau along with physical activities that are appreciated by the community to achieve its goals. Participants reflected positively about the fit of the programme to their values. The use of tuakana and kaiarahi is consistent with the literature on community health workers (CHW) [51, 52]. CHW are frequently employed with Indigenous communities in order to connect culturally with participants and systematic reviews demonstrate positive health gains from interventions delivered by CHW [31, 32].
The current findings are also supportive of the benefits of using participatory research approaches to develop and adapt lifestyle interventions for risk factors associated with diabetes, cardiovascular disease, and obesity [20,21,22,23]. Participatory research approaches such as CBPR and HPW are frequently used with Indigenous communities to address health equity and improve health [17, 18, 53, 54]. Participatory approaches establish strong relationships and emphasise community strengths that help to overcome historical mistrust and also build capacity and change systems and policies for community benefit [55,56,57].
Overall, we deemed this pilot study to develop/adapt a lifestyle intervention to reduce risk factors for diabetes and related conditions for Māori men a success. We conclude that a customised and reflexive approach contributed to retention and some positive outcomes. An effective intervention will need to be tailored and adapted to fit the needs of the participants and communities. A willingness to co-create and adapt is key to building rapport and trust with providers and communities. It also creates a commitment to sustain the work.
All animals are intimately associated with complex consortia of microbes inhabiting accessible body surfaces, and these microbial communities are instrumental to animal physiology and function [1]. The most densely populated part of the mammalian anatomy is the gastrointestinal (GI) tract, where the microbial cells are thought to outnumber host cells [2]. The GI tract is presumed sterile at birth, upon which colonization through exposure commences rapidly to form the GI microbiota. In addition to general exposure, factors such as diet and phylogeny have been found to be important determinants of GI microbiota composition, with GI bacterial communities highly co-evolved to specific lifestyles [3, 4]. The GI microbiota has been found to have plastic responses to changes in diet in humans [5], and in wild primate populations in response to habitat and seasonal variation [6,7,8]. A recent study even reported humanization of the primate GI microbiota as a result of captivity [9].
The effects on the GI microbiome of factors like dietary differences, genetic background, and geographical isolation can be difficult to disentangle. There is evidence to suggest that in hominids components of the GI microbiota have cospeciated with their hosts [52], indicating that microbiome-host relationships can be conserved at the species level over evolutionary time. On the other hand, there is ample evidence that the GI microbiota is highly responsive to dietary change [5, 53]. Hale et al. [54] investigated nine species of colobine monkeys held in captivity at five different locations, finding that their GI microbiotas clustered according to diet/location rather than to phylogeny. Further, Clayton et al. [9] found that the GI microbiotas of primates in a zoo diverged from their wild relatives to become more human-like, demonstrating strong environmental forcing of the GI microbial ecosystem. In our study, the four monkey populations all originate from distinct geographical locations in Ethiopia, with the three Chlorocebus species forming a phylogenetically close group. The gelada GI microbiota was clearly distinct from those of the other primates, with Bale monkeys being the most similar to geladas (Fig. 3). The Bale monkeys in this study subsist mainly on the shoots and leaves of bamboo (Arundinaria alpina), a species in the family Poaceae which also includes grasses and sedges, although Bale monkeys are not graminivores because they are not grazers [27]. Nevertheless, geladas and Bale monkeys may both be considered ecological specialists with Poaceae as a major dietary component, and the Bale monkey GI microbiota was clearly distinct from that of vervets and grivet. Vervets and grivets are ecological generalists with varied diets of fruit, leaves, and seeds [28]. In addition, some populations raid a variety of human crops [55, 56]. Thus, it is perhaps not surprising that these two species showed the closest similarity to human adults. Human adults in western countries generally have varied diets and lifestyles, which may explain the higher between-sample distances within this group (Fig. 5a). Human infants are known to have dynamic GI microbiotas with a high degree of inter-individual variation [57] which is reflected in the extremely high between-sample distances (Fig. 5a) and the subsequent diffuse clustering (Fig. 3) in this group. This phenomenon has been reported in a previous study [22] and may mean that infants are subject to microbial colonization through random exposure, while adults have stronger selection against opportunistic colonization. Ley et al. [3] documented a diversity gradient from herbivores to omnivores to carnivores, with the highest diversity in herbivores. In agreement with these results, humans harbored much less diverse microbiotas relative to monkeys (Fig. 5b, c), with OTU diversity greatly reduced in human infants relative to human adults, also in keeping with previous work [22].
We conducted this study in the northwest of Iran: Ardabil and East Azerbaijan provinces. Almost all the people living in these areas have Azari-Turkish background with different sociocultural values influencing their lifestyle. Diabetes is a major concern in these areas [22, 23] where not only have previous studies shown inadequate diabetes care and high prevalence of complications but relatively poor quality of life among these people has been referred to as well [24,25,26,27]. 2b1af7f3a8