# Operationalizing Co-Design in Exercise Interventions with Indigenous Peoples in Australia: Development and Cultural Adaptation of the PrIDE Tools

## TL;DR

This paper describes the development of culturally adapted exercise tools for Indigenous Australians to address diabetes and heart disease through co-design and transparent methods.

## Contribution

The study introduces the PrIDE tools, developed through Indigenous-governed co-design and systematic cultural adaptation frameworks.

## Key findings

- Four culturally adapted tools were developed using Indigenous governance and frameworks like CHRI and COM-B.
- Transparent documentation via MADI supports reproducibility and cultural safety in health interventions.
- The Success Plan integrates clinical yarning into routine practice for culturally congruent care.

## Abstract

Public health relevance—How does this work relate to a public health issue?
Indigenous Australians experience a disproportionate burden of type 2 diabetes and cardiovascular disease, with earlier onset, higher prevalence, and greater complications than other Australians, reflecting the profound impacts of colonization and ongoing structural inequities.Limited peer-reviewed evidence exists on culturally adapted exercise interventions co-designed with Indigenous Australians living with type 2 diabetes; substantial gaps remain in transparent reporting of Indigenous governance, cultural adaptation processes, and behavioral mechanisms.

Indigenous Australians experience a disproportionate burden of type 2 diabetes and cardiovascular disease, with earlier onset, higher prevalence, and greater complications than other Australians, reflecting the profound impacts of colonization and ongoing structural inequities.

Limited peer-reviewed evidence exists on culturally adapted exercise interventions co-designed with Indigenous Australians living with type 2 diabetes; substantial gaps remain in transparent reporting of Indigenous governance, cultural adaptation processes, and behavioral mechanisms.

Public health significance—Why is this work of significance to public health?
This study advances the transparent documentation of systematic cultural adaptation through Indigenous-governed co-design, applying structured frameworks (CHRI Model, MADI, CREATE Quality Appraisal Tool, COM-B model) to address critical gaps in reproducibility and knowledge translation.Indigenous-governed co-design processes centered Indigenous knowledges and leadership beyond what consultation-based approaches achieve, demonstrating how behavior change mechanisms can be operationalized in culturally congruent ways that honor Indigenous epistemologies while maintaining evidence-based effectiveness.

This study advances the transparent documentation of systematic cultural adaptation through Indigenous-governed co-design, applying structured frameworks (CHRI Model, MADI, CREATE Quality Appraisal Tool, COM-B model) to address critical gaps in reproducibility and knowledge translation.

Indigenous-governed co-design processes centered Indigenous knowledges and leadership beyond what consultation-based approaches achieve, demonstrating how behavior change mechanisms can be operationalized in culturally congruent ways that honor Indigenous epistemologies while maintaining evidence-based effectiveness.

Public health implications—What are the key implications or messages for practitioners, policy makers and/or researchers in public health?
Health services seeking to develop culturally safe exercise interventions can use the PrIDE co-design methodology as a model, with transparent MADI documentation providing detailed guidance for systematic cultural adaptation and the Success Plan demonstrating the integration of clinical yarning into routine practice.Researchers and policymakers should prioritize Indigenous leadership and governance in systematic cultural adaptation using established frameworks, recognizing that documenting development processes is as critical as evaluating outcomes for achieving cultural safety, community trust, and scalability of health interventions.

Health services seeking to develop culturally safe exercise interventions can use the PrIDE co-design methodology as a model, with transparent MADI documentation providing detailed guidance for systematic cultural adaptation and the Success Plan demonstrating the integration of clinical yarning into routine practice.

Researchers and policymakers should prioritize Indigenous leadership and governance in systematic cultural adaptation using established frameworks, recognizing that documenting development processes is as critical as evaluating outcomes for achieving cultural safety, community trust, and scalability of health interventions.

Indigenous Australians experience a disproportionate burden of type 2 diabetes mellitus and cardiovascular disease. While clinician-led, community-based exercise programs are effective in general populations, limited peer-reviewed evidence is available describing culturally adapted exercise interventions with Indigenous Australians that transparently reports governance, cultural adaptation, and theoretical design. This paper reports the co-design and development of tools for the Preventing Indigenous Cardiovascular Disease and Diabetes through Exercise (PrIDE) study, an adaptation of the Beat It program that incorporates wearable technology. Using the Co-design Health Research and Innovation Model, four tools were developed with Indigenous governance through a Consumer Advisory Group and a project-specific Consumer User Panel. Three tools were culturally adapted—the PrIDE Exercise Program, the Strong Spirit Strong Self self-efficacy assessment, and Keep Your Heart Strong educational materials—and a newly developed tool, the Success Plan. Cultural adaptations were prospectively documented using the Model for Adaptation Design and Impact, and all tools were assessed using the Aboriginal and Torres Strait Islander Quality Appraisal Tool. Behavior change mechanisms were mapped using the COM-B model. This paper provides transparent documentation of culturally adapted theory-informed tool development to support reproducibility and knowledge translation. The evaluation of effectiveness, acceptability, and psychometric properties will be reported following PrIDE implementation.