Facilitators and Barriers to Physical Activity and Sport Participation Experienced by Aboriginal and Torres Strait Islander Adults: A Mixed Method Review

Physical activity has cultural significance and population health benefits. However, Aboriginal and Torres Strait Islander adults may experience challenges in participating in physical activity. This mixed methods systematic review aimed to synthetize existing evidence on facilitators and barriers for physical activity participation experienced by Aboriginal and Torres Strait Islander adults in Australia. The Joanna Briggs Institute methodology was used. A systematic search was undertaken of 11 databases and 14 grey literature websites during 2020. The included studies reported physical activity facilitators and barriers experienced by Aboriginal or Torres Strait Islander participants aged 18+ years, living in the community. Twenty-seven studies met the inclusion criteria. Sixty-two facilitators were identified: 23 individual, 18 interpersonal, 8 community/environmental and 13 policy/program facilitators. Additionally, 63 barriers were identified: 21 individual, 17 interpersonal, 15 community/environmental and 10 policy/program barriers. Prominent facilitators included support from family, friends, and program staff, and opportunities to connect with community or culture. Prominent barriers included a lack of transport, financial constraints, lack of time, and competing work, family or cultural commitments. Aboriginal and Torres Strait Islander adults experience multiple facilitators and barriers to physical activity participation. Strategies to increase participation should seek to enhance facilitators and address barriers, collaboratively with communities, with consideration to the local context.


Introduction
There are approximately 370 million First Nations people globally, with rich and unique cultures [1]. However, many First Nations people experience significant inequity across personal, interpersonal, community and policy domains [20]. Interpersonal factors played a significant role, with friends and family engaging in physical activity being an important determinant of participation, and the concept of "shame" being a particular deterrent. Children in remote areas often faced more barriers regarding access to facilities, activities, and transport and, in particular regions, uncomfortable weather patterns. A 2010 literature review, framed through the socio-ecological model, similarly identified the barriers of shame, lack of facilities and climate, as well as a lack of time and resources to support participation, that stemmed from socioeconomic disadvantage and family and work commitments [21]. However, physical activity was important in the lives of Aboriginal and Torres Strait Islander people, particularly for its role in social and community connections [21].
A systematic mixed methods review focusing on the adult population would give comprehensive understanding of facilitators and barriers to physical activity and sport for Aboriginal and Torres Strait Islander adults. Synthesis of this evidence base, using a socioecological framework, will provide insights into physical activity and sport participation and inform future program and policy design. This review aims to provide a synthesis of the current research exploring facilitators and barriers to participation in physical activity and sport experienced by Aboriginal and Torres Strait Islander adults.

Materials and Methods
This review uses the Joanna Briggs Institute mixed methods systematic review methodology [22] and is reported using the PRISMA statement for systematic reviews [23]. The full review protocol has been reported separately [24] and has been registered with PROSPERO (CRD42020214112).
The search was conducted between September and December 2020. A university librarian was consulted to advise on the search strategy. Keywords and index terms were developed for the four concepts of physical activity and sport, facilitators and barriers, Aboriginal and Torres Strait Islander people, and Australia. Eleven databases were searched: MEDLINE, CINAHL, EMBASE, Scopus, SPORTSDiscus, PsycINFO, Informit (ATSIhealth and AUSPORT), the Database of Abstracts and Reviews of Effects (DARE), the Cochrane Library, The Campbell Library and ProQuest Dissertations and Theses. Grey literature and websites were also searched, including Google Scholar, Australian Indigenous Health-InfoNet, Australian Institute of Aboriginal and Torres Strait Islander Studies, Australian Institute of Health and Welfare, Sport Australia, the Lowitja Institute and state and territory government sport and recreation documents. The search strategy was modified for these sites. For example, Google Scholar was searched with different combinations of "Aboriginal" or "Indigenous" and "sport" or "physical activity". To limit results by relevance, the results were limited to "all in title".
Studies were included if participants were Aboriginal or Torres Strait Islander adults living in Australia. Studies involving non-Indigenous adults or participants aged younger than 18 were considered if Aboriginal and Torres Strait Islander adult participants made up >50% of participants or if outcomes were reported separately. Studies describing community-based experiences were also included. Studies were included if they reported on facilitators, barriers, or related terms in relation to participation in all forms of physical activity and sport. Examples of "facilitator" synonyms include motivation or enabler, and synonyms for "barrier" include disincentive or obstacle. Facilitators or barriers needed to be reported in terms of the experiences of Aboriginal and Torres Strait Islander adults and not epidemiological correlates or observations by non-Indigenous participants. All structured and unstructured, group or individual programs were considered, and multicomponent programs were considered for inclusion if physical activity and sport outcomes were reported separately. All states and regions of Australia were considered if participants were living in the community. All qualitative, quantitative, and mixed-methods studies were considered for inclusion.
Studies that described non-contemporary experiences from before the year 2000 were excluded, as these were considered to be of less immediate relevance to current physical activity and participation. Experiences of elite athletes and sport coaches were excluded, as were programs delivered at live-in facilities and institutional settings, such as inpatient hospital programs. Reviews that examined physical activity and Aboriginal and Torres Strait Islander adults were checked for relevant studies. Only studies published in English were included.
All study and website citations yielded were imported into Covidence [25] and duplicates were removed. All abstracts were screened using the inclusion and exclusion criteria by the first author, with the last author independently screening approximately 25% of the abstracts. The full texts of studies included after abstract screening were uploaded to Covidence and all were screened by the first author and independently crossed-checked by the last author.
Data extraction was completed using a modified proforma from a previous Aboriginal and Torres Strait Islander physical activity and sport systematic scoping review [10]. For quantitative studies, phenomena data were in the form of data-based outcomes of descriptive or inferential statistical tests. For qualitative studies, phenomena data were in the form of themes or subthemes.
Data were synthesized following a convergent integrated approach [26]. The extracted quantitative data were converted into sentence summaries and then assembled with the qualitative data based on similar meanings in order to form the identified facilitators and barriers. These findings were categorized using a modified version of the socio-ecological model of health [20]. Within each level of the model, findings were further subcategorized based on similarity, and subcategories were then used to form a set of integrated findings in the form of line of action statements.

Critical Appraisal
The included studies were critically appraised by two independent reviewers for methodological quality using the Mixed Methods Appraisal Tool (MMAT) [27]. The included studies were also assessed for the quality of health research from a First Nations perspective prior to inclusion in the review using the Aboriginal and Torres Strait Islander Quality Appraisal Tool (QAT) [28]. Any disagreements that arose between the reviewers were resolved through discussion, or with a third reviewer where necessary.

Study Inclusion
A total of 1423 studies were identified, and 1031 studies remained after duplicates were removed. After abstract screening, 102 full texts were retrieved for review. Ultimately, 27 studies were included ( Figure 1). Three studies [29][30][31] were different analyses of the same data set and were grouped together for data extraction and presentation. Four studies were identified in grey literature [18,[32][33][34].

Socio-Ecological Level
Facilitators Barriers

Program delivery
Provision of transport [45,53] Structured program [53] Free program [39,45,47] Positive program experience [39] Convenient times and location [39] Provision of childcare [39] Program meets needs and expectations [39] Professionalism/well-organised program [39] Program connected to local Aboriginal community-controlled health organisation [45] Flexibility [45] Variety of exercises in program [53] External support Supportive employers [34] Support from services [35] Program delivery No one to run program [54] Session times and frequency [47,54] Loss of program funding [54] Inconvenient program location [39] Program different to expectations, mismatched with fitness level [39] Lack of sustainable, local physical activity programs [42,43] Insufficient number of programs and locations [44] Lack of motivation, confidence or initiative around chronic disease self-management [44] Lack of knowledge about programs [44] Reliance on welfare [43] Table 3 presents the facilitators and barriers to physical activity and sport participation experienced by Aboriginal and Torres Strait Islander adults, organized by geographic location. These findings are summarized and described, and interwoven with the five Action Statements.

Individual Facilitators and Barriers
Action Statement 1: Personal attitudes and life circumstances of Aboriginal and Torres Strait Islander people should be considered in effectively identifying and addressing opportunities for physical activity and sport and potential barriers.
Sub-categories: Self-beliefs and attitudes, physical activity aligned with daily life and personal circumstances. Numerous attitudes, expectations and self-beliefs were identified that could either facilitate or hinder participation. A multitude of personal circumstances influencing participation were identified, including health issues, socioeconomic factors, physical activity aligning with other life activities, and competing commitments. In urban studies, intrinsic self-motivation [32,39,49] facilitated participation, as did numerous personal motivators, in-cluding poor body image perception, [32] curiosity and the desire to support research. [39] In one study, a self-stereotyped belief of being a "natural athlete" facilitated participation. [31] In another study, use of digital health trackers were facilitators as they increased self-awareness of activity levels, however, difficulties with the technology was a barrier. [50] A lack of self-motivation was a barrier in all geographic locations [32,33,36,44,49,50], while a lack of confidence around trying something new and general attitudes towards physical activity were barriers in only one urban and rural/regional study [50]. The practical need to be active in instances, such as walking for transport, was a facilitator reported in different geographic locations [33,51], while one study reported the integration of physical activity into daily life and culture as a facilitator [31]. Lack of transport and financial constraints were barriers in numerous studies [31][32][33][34]39,41,42,[46][47][48]54]. Resource constraints were a barrier in two studies [18,38] and unemployment was a barrier in one rural/regional study [47]. Lack of time was a barrier across various locations, and was often associated with work, study, or other commitments [33,34,39,47,49,50]. Other individual circumstance barriers included other travel commitments in rural/regional areas [47], and major life events in an urban study. [39] Action Statement 2: Promoting the holistic health and personal benefits of physical activity, whilst also addressing the challenges of those facing specific physical or health challenges, may facilitate participation.
Subcategories: Expected and realized personal benefits, health goals and issues and overcoming specific challenges A range of health-related motivators were described as facilitating participation, as was having expectations of and realizing various benefits from physical activity. However, a number of health or physical issues functioned as barriers, requiring strategies in order to overcome them. Expecting benefits from physical activity was a facilitator for participating in physical activity across various geographic locations [33,49]. The realized benefits that facilitated participation included enjoyment [36,38,39,53], improved health in urban studies [39,44,53], and having a purpose in remote studies [35,54]. Health-related facilitators across locations included personal motivations for fitness [36,38,47,49] and having knowledge of First Nations health issues and risk factors [36,41]. Across various locations, people with previous experiences of illness or injury, or current health problems, were motivated to participate in physical activity, often in order to mitigate disease progression [35,36,39,41,47,51]. Other facilitators included a desire for mental wellbeing [36,38] and, in remote studies, a desire for weight control [36,51] and feeling happy and strong [35]. However, injury or illness was a barrier in all locations [33][34][35][36][37]42,45,49], and poor mental health was a barrier in one study [35].
Disability was a physical individual barrier in several locations [35,37,42]. In remote areas, perceived age and weight constraints were a barrier, as was changing long-term behavior in those with or at risk of type 2 diabetes [36,52]. However, certain strategies were facilitators, such as making slow, small behavioral changes [52] and using assistive devices and modifying activities in instances of disability [35]. Subcategories: Impacting and being impacted by other people, family and peers and social network.

Interpersonal Facilitators and Barriers
The importance and influence of family, friends, community members and role models regarding physical activity participation was reflected in many of the facilitators and barriers. Fostering interpersonal connections while addressing broader social issues, such as racism or conflict, may play an important role in facilitating physical activity participation.
Across geographic locations, the influence of role models was an interpersonal facilitator for participation in physical activity [34,36,48], as was the influence of family and friends [36,44,46,48]. In one study the importance of having a role model or program leader of the same gender was highlighted as a facilitator [47]. Wanting to be a role model for children and others was a facilitator [30][31][32]46]. In one study, the influence of having health information shared with an individual on social media was a facilitator [48]. However, in one regional/rural study stigma around physical activity had a negative influence on participation [47]. Experiences of racism was a barrier in all geographic locations, as was public judgement in one urban study [31,33,38,41,42]. However, one urban study described wanting to challenge racism as a facilitator [38]. Support from family, including provision of material and instrumental assistance, was a facilitator across locations [35,39,46,47,52]. Inclusion of family members in physical activities was also a facilitator [38,42,47]. On the inverse, a remote study described a lack of family inclusion as a barrier [54], while a rural study described a lack of family support as a barrier [47]. Across locations, family commitments, including caring for children, were a common barrier [31,33,39,42,43,45,46,49,50], as was prioritizing children's participation in sport and physical activity [33]. For women, gendered roles and responsibilities, such as housework, were barriers [32,43]. In urban studies, family and community conflict were barriers to participation [34,38].
Across various locations, relationships with program staff that were supportive, respectful, or encouraging were facilitators [32,36,45,47,53], as was receiving peer support [38,47,52,53]. The opportunity for social connections was a commonly reported facilitator [31,32,34,38,39,54]. Additionally, the opportunity to participate in group activities or have exercise companions were facilitators and, in urban studies, the participation of others from a participant's community network and a supportive, positive group environment were facilitators [42,45,46,53]. For some urban women, a women-only group was a facilitator [29,30].
Shame and embarrassment were barriers across various geographic locations, but were noted as becoming less so in some communities [33,35,36,43,47]. Lack of support from peers was a barrier [32,47]. Concern for the safety of older people was barrier to going On-Country in remote areas [18], while a non-Indigenous group atmosphere was a barrier in a rural/regional study [46]. In urban locations, conflict with program staff was a barrier [34], and peer rivalry was a barrier for sport participation [38]. In one individualized intervention, a lack of social interaction was a barrier to participation [50]. Finally, across locations, cultural obligations, including funerals, was a barrier [18,45,47].

Community and Environment Facilitators and Barriers
Statement 4: Respecting connections to culture and supporting communities to be supportive, safe, and well-resourced may facilitate participation in physical activity and sport.
Subcategories: Community context, safety and resources, community connection and connecting with culture.
Community-level facilitators and barriers suggest that adequate infrastructure and neighborhood safety are important factors influencing physical activity. Community relationships also play an important role that can help or hinder physical activity participation. Connecting to culture and access to culturally safe places and activities may be an important factor for Aboriginal and Torres Strait Islander people for engaging in physical activity.
Access to equipment in an urban study [53] and appealing and varied locations for exercise in a remote study [36] were community and environmental factors that facilitated participation. However, across various locations a lack of available services and physical activity opportunities was reported [31,33,42]. Similarly, across various locations unsafe or inadequate infrastructure [31,32,36,46] and general safety concerns [36,42,46] were a barrier, the latter were particularly noted among women [36,42,46]. A lack of access to facilities was a barrier in a rural study [47]. In remote locations, dangerous dogs were a barrier [36], and unappealing outstations and the distractions of community life were barriers to participating in On-Country physical activity [18]. Urban traffic and urban living itself were barriers [39,42]. Additionally, local weather and climate were barriers (e.g., heat or rain) [18,32].
Community-wide healthy lifestyle changes or attitudes were a facilitator to individual physical activity across various locations [36,48]. In an urban study [38] and a remote study [36], the ability to connect with community was a facilitator. However, the pressure of community expectations to excel was a barrier for sport participation [38]. High death rates had wide community impacts and were a barrier [34]. In a rural/regional study, unfriendly neighborhood environments was a barrier [46], while in a remote study, distractions of community life was a barrier [18].
Participating in cultural activities was a facilitator across various geographic locations [35,40,51]. Having access to a culturally appropriate and safe environment [31,39,49], or an Aboriginal and Torres Strait Islander specific facility or activity [41] were also facilitators. In an urban study, a sense of community history and pride associated with sport were facilitators [38]. Culturally inappropriate activities and a lack of cultural inclusiveness were barriers to participation across locations [33,51]. Participants in urban areas reported disrupted connection with culture and land as barriers [41].

Policy and Program Facilitators and Barriers
Statement 5: Physical activity and sport programs should be sustainably resourced and receptive to participants' needs and expectations to facilitate participation.
Subcategories: Program delivery and external support. Physical activity and sport programs can facilitate attendance with sufficient and sustainable funding and staffing, and with program designs that accommodate the needs and expectations of Aboriginal and Torres Strait Islander people. Many features of physical activity programs and interventions were considered to be facilitators, including being cost-free and structured, and in urban studies, these included the provision of transport, childcare and professionally delivered and well-organized programs [39,45,47,53], although flexibility for participants was also a facilitator [45]. Other urban program facilitators were convenient times and locations, variety in activities, meeting needs and expectations and being connected with an Aboriginal community-controlled health organization [39,45,53]. Having a positive program experience facilitated ongoing participation [39]. Table 3. Facilitators and barriers to physical activity and sport participation experienced by Aboriginal and Torres Strait Islander adults, by geographic location.

Socio-Ecological Level
Urban Regional/Rural Remote

Program and Policy
Free program [31,39,45] Supportive employers [34] Provision of transport [45,53] Structured program [53] Positive program experience [39] Convenient times and location [39] Provision of childcare [39] Program meets needs and expectations [39] Professionalism/ well-organised program [39] Program connected to local Aboriginal community-controlled health organisation [45] Flexibility [45] Variety of exercises in program [53] Inconvenient program location [39] Program different to expectations, mismatched with fitness level [39] Lack of sustainable, local physical activity programs [42] Insufficient number of programs and locations [44] Lack of motivation, confidence of initiative around chronic disease self-management [44] Lack of knowledge about programs [44] Free program [47] Session times and frequency [47] Support from services [35] No one to run program [54] Session times and frequency [54] Loss of program funding [54] Lack of sustainable, local physical activity programs [43] Reliance on welfare [43] In a rural/regional study [47] and a remote study [54], finding feasible session times and frequency were a barrier to participation and, in a remote setting, loss of program funding and having no one to run programs were barriers [54]. However, an urban and a remote study also cited lack of sustainable local physical activity initiatives as a barrier [42,43]. Other urban program barriers were a lack of knowledge about the program [44], a mismatch of participant expectations and fitness level with the program [39], inconvenient program location [39] and an insufficient number of programs and locations [44]. Reliance on welfare was a policy barrier to participation in physical activity in one study, as past policies had an ongoing disempowering effect on the community, leading them to depend on external agencies to provide participation opportunities [43]. Organizations could play a role in facilitating physical activity by supporting employees to attend programs [34].

Discussion
This mixed methods systematic review synthesized 27 studies, finding many diverse facilitators and barriers to physical activity and sport participation that are experienced by Aboriginal and Torres Strait Islander adults. Most facilitators and barriers identified were individual and interpersonal, as categorized by the socio-ecological model of health [20]. There were similar numbers of facilitators and barriers identified at each level of the socioecological model, except for at the community level where more barriers than facilitators were identified. Most studies were qualitative and used similar methods, generally using individual or group interviews or the First Nations methods of Yarning and Dadirri. Yarning involves a conversational process of knowledge and story sharing [55] and Dadirri is a way of life encapsulating deep listening, sharing and trust [56]. The use of these methods was appropriate to elicit in-depth and culturally relevant complexities surrounding the unique facilitators and barriers to physical activity and sport participation experienced by Aboriginal and Torres Strait Islander adults. First Nations methods and worldviews were also evident in the included mixed-method and quantitative studies and their collective synthesis gives rich data on lived experiences.
The review found that the personal attitudes and life circumstances of Aboriginal and Torres Strait Islander people should be considered for effectively identifying and addressing opportunities for physical activity and sport, and potential barriers. This finding is relevant at multiple levels of the socioecological model, where personal attitudes pertain to the individual and inter-personal level and the upstream levels of community, environment, policy and program that impact life circumstances. Given the complex historical factors that have shaped Aboriginal and Torres Strait Islander health and wellbeing and life experiences today, strategies to encourage physical activity and sport participation and to reduce barriers to participate must be relevant to contemporary experiences [2].
Many personal facilitators and barriers were associated with concepts of health and wellbeing highlighting, as summarized in Action Statement 2, that promoting the health and personal physical activity benefits whilst addressing the challenges of those facing specific physical or health challenges is crucial. The desire to improve health and fitness were facilitators for physical activity, especially if someone had experienced illness or injury or was living with a chronic disease. Two studies [41,47] explain this through the health belief model [57], where perceived health threats and cues for action can facilitate behavior change, although the cultural relevance of the model is unknown. Interrelationships were also seen between physical activity participation and mental health, with feeling happy and strong and wanting stress relief facilitating participation, while poor mental health was a barrier to participation. This highlights the role that sport and physical activity can play in improving wellbeing, given the historical factors and intergenerational trauma that have led to a high burden of mental illness and stress for Aboriginal and Torres Strait Islander people [58]. The positive impact of sport and physical activity on social and emotional wellbeing experienced by Aboriginal and Torres Strait Islander people is suggested [10], but greater empirical evidence is required across the life course.
Barriers such as a lack of access to transport, financial constraints and unemployment may interrelate with lower socioeconomic status. Again, due to the ongoing impacts of European invasion and racial discrimination, Aboriginal and Torres Strait Islander adults are disproportionally within the lowest income quintile, with implications for accessing health-related goods and services [6]. A recent longitudinal study found a statistically significant association between area socioeconomic status and participation in physical activity among Australian adults [59]. Among Aboriginal and Torres Strait Islander adults in NSW, high physical activity levels were associated with a higher socioeconomic position [60]. The present review also demonstrated several program factors that facilitate participation and overcome these barriers, including the provision of transport and programs at no cost to participants, which suggest important elements for program modification and future design [61].
The importance of social and family connections was very apparent, with opportunities for these connections facilitating physical activity and sport participation, whilst family and cultural obligations may be barriers to participation. Further, respecting connections to culture and supporting communities to be supportive, safe, and well-resourced may facilitate physical activity and sport participation. These findings highlight the central roles of family, community, kinship and Country for Aboriginal and Torres Strait Islander culture, society [62], health and wellbeing [63]. This has significant implications for physical activity program providers, who can facilitate participation by ensuring family and community inclusion and togetherness. Similarly, integrating physical activity into daily life and culture is an important facilitator and should be supported. There is emerging evidence that cultural and Country-based activities that include physical activity improve health and wellbeing [64]. Additionally, having role models and desiring to be a role model for others was a facilitator for physical activity. This was also reflected in the review of child and adolescent barriers and facilitators, [20] where family participation and role modelling had flow-on effects for physical activity in young Aboriginal and Torres Strait Islander people, further supporting the need for inclusive, culturally relevant, and family-oriented physical activity initiatives.
Experiences of racism were a barrier for physical activity and sport participation. The need for culturally safe facilities, appropriate activities and inclusive, respectful staff were all described as facilitators and provide important insights for program providers. This corroborates the proposed roles of Aboriginal and Torres Strait Islander sports teams and programs in providing opportunities to assert identity and increase the visibility of success, as well as being hubs for cultural safety and community connection [65]. In the present review, self-stereotyping around perceptions of Aboriginal and Torres Strait Islander people's "natural ability" in sports was a facilitator to participation. This stereotype has been upheld previously and, while self-belief may enable participation, the stereotype has been critiqued as undermining other capabilities of Aboriginal and Torres Strait Islander people, such as intelligence, and limiting avenues for success in other fields [66].
Transport and logistical issues were barriers across various geographic contexts, but with some variation according to remoteness. A lack of public transport was a reported issue in rural and remote locations, with remote participants also facing issues of high fuel costs and difficulties related to travelling between communities. In urban locations, reliability and affordability of transport was an issue, and people, at times, needed to walk significant distances to access facilities. Previous research with Aboriginal people aged 45 years and over also indicated the importance of neighborhood characteristics, such as a lack of public transport, where supportive neighborhood environments were associated with higher physical activity participation [60]. In this review, traffic had negative effects on motivation in urban areas, and urban dwelling and disrupted connections with Country and culture emerged as barriers to participation. The cultural appropriateness of activities, like running and swimming, varied significantly across the studies and cultural groups, demonstrating the importance of local context and using collaborative approaches for programs and environmental provision for community-based activities and facilities.
Several barriers specific to women were identified, including child-raising and household obligations and environmental safety concerns. Women prioritized the physical activity of their partners who were the main income earners, reflecting the roles Aboriginal women have played as "enablers" for the participation of others. Shame, a complex concept that can involve knowledge and emotions arising from being singled out for negative and positive reasons [67], was a barrier for women, but this was also challenged as an "old-fashioned" notion [43]. Having women-only activities was a strong facilitator of sport and physical activity participation. Understandings of physical activity were also noted to be different between genders, with women including not just sport but also household work and other activities as physical activity. Understanding the physical activity and sport experiences of Aboriginal and Torres Strait Islander women is particularly important, given gender disparities demonstrated in demographic studies, particularly among adolescent females [68]. At the policy and program level, our findings revealed that physical activity and sport programs should be sustainably resourced and receptive to participants' needs and expectations to facilitate participation. Physical activity and sport program provision for Aboriginal and Torres Strait Islander people is common but program impact could be better determined [61]. Several studies were program evaluations, yielding facilitators that can be considered in program design and adaptation, including addressing affordability, transport and incorporating variety and flexibility. Funding and long-term sustainability were identified as program barriers, with "one-off" events viewed as insufficient to have an impact on participation. Thus, true community engagement will play a critical role in facilitating sustainable physical activity and sport program offerings for Aboriginal and Torres Strait Islander people; recommendations that are commonly made but less often realized. Such engagement includes community co-design, leadership and governance of programs that are inherent, as per the Aboriginal and Torres Strait Islander QAT, along with political support and sustainable funding sources.
In this systematic review we used this QAT to assess the included studies. This recently developed tool is the first to assess research quality from an Aboriginal and Torres Strait Islander perspective [28]. The areas in which the most studies performed well were using a strengths-based approach, using First Nations research paradigms and strengthening capacity for Aboriginal and Torres Strait Islander people. However, very few studies reported Aboriginal and Torres Strait Islander research governance, community control over collection and management of research materials, or negotiated agreements of participant and community rights of access to existing intellectual and cultural property. No studies indicated a negotiated agreement had been made to protect Aboriginal and Torres Strait Islander peoples' ownership of the intellectual and cultural property created through the research. Overall, there was a lack of clear reporting of steps taken to ensure the research aligned with community interests, although some studies had included more details in associated papers, such as protocols. The QAT provides an opportunity for researchers to improve the conduct and report of research by using the checklist as a guide for ethical research practices and by including, in publications, evidence of the actions taken to ensure that the research reflects the interests of Aboriginal and Torres Strait Islander communities.
Utilizing a mixed methods review methodology is a strength of this paper, as it allows for the identification and synthesis of concepts across a variety of study types [69]. Categorizing facilitators and barriers with a socio-ecological model is another strength, as it allows for understanding of interacting influences at the personal, social, environmental and political levels [70]. The review also complements a recent Aboriginal and Torres Strait Islander child physical activity and sport review, providing comprehensive evidence synthesis across the life course [20]. Furthermore, the review comprehensively extracted, synthesized and reflected on studies examining the complex terms "barrier" and "facilitator" in the context of Aboriginal and Torres Strait Islander experiences of physical activity and sport [11]. There are some limitations: only two longitudinal studies were identified, and, thus, understandings of changes to facilitators and barriers over time is very limited. While most studies used purposive or convenience sampling, this is appropriate for qualitative studies [71] and the importance of the local cultural context and diversity can be emphasized. Nevertheless, caution must be taken when generalizing findings across Aboriginal and Torres Strait Islander populations, regardless of sampling methods, given the cultural and contextual diversity in these populations [5]. The incorporation of two diverse quality assessment tools [27,28] allows for better understanding of the strength and cultural relevance of evidence and indicates how research can be better articulated in order to reflect on and respond to community priorities [27].
Finally, facilitating participation in physical activity is likely to have a positive effect on Aboriginal and Torres Strait Islander health. [72] However, a holistic approach is required for improving health outcomes, given the many social and cultural determinants which impact health [4]. Addressing these determinants is likely to address many of the barriers to physical activity that are identified in this review, including issues of affordability and access. Given the multitude of facilitators and barriers influencing participation in physical activity and sport for Aboriginal and Torres Strait Islander people, future strategies should strongly consider, plan for, and evaluate the impact of facilitators and barriers for participation.

Conclusions
This mixed methods systematic review has identified multiple, complex facilitators and barriers experienced by Aboriginal and Torres Strait Islander adults participating in physical activity and sport across different contexts and locations. The implication of these findings is for programs and decision makers to address these factors in collaboration with Aboriginal and Torres Strait Islander communities and with consideration of the local community context, to facilitate increased participation. The five action statements generated through the synthesis of the mixed method studies within this review give clear practical guidance for future program and planning, as well as for improving current program delivery. More broadly, public policy that recognizes and seeks to address the social determinants of health affecting Aboriginal and Torres Strait Islander people will help to address some of the upstream barriers to participation and create a supportive environment to facilitate participation.