- Email: [email protected]
Participatory action research opens doors: Mentoring Indigenous researchers to improve midwifery in urban Australia
G Model WOMBI 732 No. of Pages 6
Women and Birth xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
Women and Birth journal homepage: www.elsevier.com/locate/wombi
Participatory action research opens doors: Mentoring Indigenous researchers to improve midwifery in urban Australia Sophie D. Hickeya,* , Sarah-Jade Maidmenta , Kayla M. Heinemanna , Yvette L. Roea , Sue V. Kildeaa,b a Midwifery Research Unit, Mater Medical Research Institute-University of Queensland, Level 2, Aubigny Place, Raymond Tce, South Brisbane QLD 4101, Australia b School of Nursing, Midwifery and Social Work, University of Queensland, St Lucia, QLD 4072, Australia
A R T I C L E I N F O
A B S T R A C T
Article history: Received 15 February 2017 Received in revised form 20 October 2017 Accepted 25 October 2017 Available online xxx
Problem: There is increasing demand for capacity building among the Aboriginal and Torres Strait Islander (Indigenous) maternal and infant health workforce to improve health outcomes for mothers and babies; yet few studies describe the steps taken to mentor novice Indigenous researchers to contribute to creating a quality evidence-base in this space. Background: The Indigenous Birthing in an Urban Setting study is a partnership project aimed at improving maternity services for Indigenous families in South East Queensland. Aim: To describe our experience setting up a Participatory Action Research team to mentor two young Indigenous women as research assistants on the Indigenous Birthing in an Urban Setting study. Methods: Case study reflecting on the first six months. Findings: Participatory Action Research was a very effective method to actively mentor and engage all team members in reflective, collaborative research practice, resulting in positive changes for the maternity care service. The research assistants describe learning to conduct interviews and infant assessments, as well as gaining confidence to build rapport with families in the study. Reflecting on the stories shared by the women participating in the study has opened up a whole new world and interest in studying midwifery and child health after learning the difficulties and strengths of families during pregnancy and beyond. Discussion: We encourage others to use Participatory Action Research to enable capacity building in the Aboriginal and Torres Strait Islander midwifery workforce and in health research more broadly. © 2017 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.
Keywords: Aboriginal and Torres Strait Islander people Participatory Action Research Capacity building Midwifery Indigenous Health Services
Statement of significance
Problem or issue There is a need to build capacity among the Indigenous maternity workforce to ‘close the gap’ in maternal and infant health outcomes between Indigenous and other Australians.
What this paper adds This case study presents our experiences of successfully using a Participatory Action Research framework to mentor two young Indigenous women with no health or research experience to conduct high quality midwifery research. The initiative was so successful that these women now want to study nursing and midwifery.
What is already known Participatory Action Research is a valued by Indigenous people as an outcomes driven, inclusive collaborative research approach.
* Corresponding author. E-mail address: [email protected] (S.D. Hickey).
1. Introduction Conducting research can be a transformative experience, particularly for those new to the field. With sufficient training and appropriate mentorship, enthusiastic community members and peer-interviewers can become empowered and critically reflective researchers. Research capacity building among the
https://doi.org/10.1016/j.wombi.2017.10.011 1871-5192/© 2017 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: S.D. Hickey, et al., Participatory action research opens doors: Mentoring Indigenous researchers to improve midwifery in urban Australia, Women Birth (2017), https://doi.org/10.1016/j.wombi.2017.10.011
G Model WOMBI 732 No. of Pages 6
2
S.D. Hickey et al. / Women and Birth xxx (2017) xxx–xxx
Aboriginal and Torres Strait Islander (here after referred to as Indigenous) maternal and infant health workforce is vital to ensure best practice, culturally relevant, evidence-based maternity care.1 This case study presents our experiences of successfully using a Participatory Action Research (PAR) framework on the Indigenous Birthing in an Urban Setting (IBUS) study to mentor two young Indigenous women with no previous health or research experience as research assistants to conduct high quality midwifery research. Given the increasing demand of specialised Indigenous maternity care services to improve Indigenous maternal and infant health outcomes,2–6 we hope that this example encourages others to nurture the growing Indigenous workforce using PAR approaches as we strive towards improving capacity for Indigenous-led midwifery research and health service provision. 2. Study background The IBUS study is a five-year prospective mixed-methods longitudinal cohort study that commenced in 2015. It was developed in partnership with two key Aboriginal Community Controlled Health Organisations that service the Brisbane region: the Institute for Urban Indigenous Health and the Aboriginal and Torres Strait Islander Community Health Service, Brisbane Limited; and Mater Mothers Hospital which provides maternity care to approximately 10,000 birthing women a year. The study’s aim is to identify improvements needed for maternity services available to women having Aboriginal and/or Torres Strait Islander babies and birthing in South East Queensland.7 Pregnant women are recruited at the Mater Mothers Hospital and The Royal Brisbane and Women's Hospital and are followed up until six months postnatal. Both hospitals run a Midwifery Group Practice for women having Aboriginal and Torres Strait Islander babies, named Birthing in Our Community and Ngarrama Indigenous Maternity Service. Through these services, women receive care from a primary midwife with the support of an Indigenous health worker. Birthing in Our Community is a partnership between the Mater Mothers Hospital, the Institute for Urban Indigenous Health and the Aboriginal and Torres Strait Islander Community Health Service, Brisbane Ltd, while Ngarrama is delivered through Queensland Health. Embedded in the IBUS study is an Indigenous workforce capacity building component which includes student midwifery cadetships, ongoing career development for Maternal and Infant Health Workers, and pertinent to this paper, the training of Indigenous research assistants (co-researchers) to undertake recruitment and data collection according to Good Clinical Practice Guidelines but also in a culturally safe and supportive manner. 2.1. Improving the health of Aboriginal and Torres Strait Islander people through Participatory Action Research Australia’s National Health and Medical Research Council’s Roadmap II8 provides strategic direction for Indigenous health research and emphasises the need to increase participation and development of research skills of the Indigenous workforce. PAR is a unique methodological approach that can inspire novice researchers through the power of research to enact sustained positive change in health service provision and planning.9 It has an emancipatory and empowerment focus in prioritising ‘local perspectives, needs and knowledge . . . through collaborations with community members throughout the research process’.10 Central importance is given to a shared commitment to change and a genuine partnered approach of ‘knowing by doing’ between the researcher and the researched11 (indeed these roles become blurred). Through its regular, reflective and responsive cycle to ‘Plan, Act, Reflect, Evaluate – Repeat!’ PAR allows for appropriate, timely and context-specific actions to be taken in both the research
design and service implementation. Study design can be flexible and can employ multi methods as appropriate, with interpretations of the data cross-checked through triangulation.11 PAR is a valued research method in Indigenous health for its capacity to collaboratively engage the Indigenous community in research.12,13 Involving Indigenous people at every stage of Indigenous health research is essential if the research is to be both meaningful, relevant and useful to effecting positive change in health outcomes among this population. 2.2. The Participatory Action Research team In May 2016, the authors formed a Participatory Action Research team that meets monthly to discuss and reflect on progress, challenges and strengths of the study, the maternity services being evaluated, and the women’s stories. The team shares their field notes and experiences so that both novice and senior team members can learn together and take positive actions to improve the study or the midwifery services directly. Yvette Roe is an early career researcher and a Njikena Jawuru woman from the Kimberley region, Western Australia, and provides mentorship for the PAR team. Sue Kildea is the Chief Investigator of the IBUS study who has extensive experience with using PAR methods for health service change to improve maternal and infant health outcomes. Sophie Hickey is an early career researcher with a social science and public health background and manages the day-to-day running of the IBUS study, including training and supervising the research assistants. Sarah Maidment and Kayla Heinemannare Indigenous research assistants for the IBUS study who recruit, follow-up and interview pregnant and postnatal women in the study. Ethics and governance approvals for the IBUS study were granted by the relevant sites. Prior to commencing their role as research assistants six months ago, both Sarah and Kayla had no previous formal experience in research. In the following section, Sarah and Kayla reflect on their experiences working with the IBUS Study. To privilege their voices, the section has been written in first person. 3. Sarah and Kayla’s experience We began as research assistants on the IBUS Study in May 2016. Kayla’s family is from the Bunjalung region from Byron Bay and she was born and raised around Brisbane. Sarah is an Arrernte woman from Alice Springs now living in Brisbane. On how we each came to this role, Kayla explains, ‘I came from hospitality to research unexpectedly as a recommendation from a relative who believed I would be great in the role. I have not looked back and have enjoyed the experience every step of the way.’ Sarah had been working in tourism and adds, ‘What interested me in this role was to talk to women and hear their stories; as a mother I feel like I can relate to these women and I liked the idea that I can give them the opportunity to reflect on their birthing experience. I think that is an important part of the birthing journey that people do not always have the opportunity to do.’ 3.1. Research training and professional development To prepare us for field work, we were trained internally on interviewing techniques, consenting procedures, and learnt about our role within the research study and its many sub-studies. With Sophie, we role-played many practice surveys and addressed what we would do in challenging hypothetical situations, including risk assessments (e.g. suicidal risk or self-harm) and referral processes. As part of our professional development training, we attended a two day Research Masterclass hosted by the Institute for Urban Indigenous Health and presented by Wardliparingga, South
Please cite this article in press as: S.D. Hickey, et al., Participatory action research opens doors: Mentoring Indigenous researchers to improve midwifery in urban Australia, Women Birth (2017), https://doi.org/10.1016/j.wombi.2017.10.011
G Model WOMBI 732 No. of Pages 6
S.D. Hickey et al. / Women and Birth xxx (2017) xxx–xxx
Australian Health & Medical Research Institute. The topics over the two days included: introduction to research, how to form a research question and how to create a research study around your research question, as well as an overview of ethics in research. The masterclass helped us to understand how research evolves from a research question and findings can be implemented into health services. Sue talked us through research and the difference between qualitative and quantitative research. She gave a presentation on her PhD to give us an idea on what participatory action research in the remote Indigenous setting looked like and explained the IBUS research framework and where we fit in before we commenced field work. We also attended a two day workshop on the Bayley Scale of Infant and Toddler Development – Third Edition (Bayley III)14 and are now trained on administering the Bayley III on the infants in the study when they are about six months old. The Bayley III is a comprehensive and interactive tool used to assess infant and toddler development, focusing on cognitive, language, and motor skills.13 It was originally developed using an American population of children to create the norms of infant and toddler developmental milestones. The purpose of administering the Bayley III in this study is to compare the norms from the United States with scores from urban Indigenous Australian infants to determine if this scale is appropriate and accurate to use in this setting. 3.2. Conducting infant assessments With ongoing supervision from Dr Gabrielle Simcock, a PostDoctoral Research Fellow in our Unit who specialises in infant growth and development, we conduct the Bayley III and surveys in the women’s homes if they have invited us. Going out on home visits together and supporting each other to accurately administer the Bayley III and conduct the interview makes us feel more confident doing the job. It is important to us to make the mothers feel comfortable with us being there. Sarah admits, ‘On my first few times administering the Bayley III assessment, I was nervous’. We do not want the women to feel judged as a parent, based on their infant’s development. Or ‘shame’18 to have us researchers at their house – some women might not have even met us in person before allowing us to visit. Shame or shame job is the term used by Aboriginal people to describe a feeling or situation that has made you really embarrassed. Shame can make you feel degraded and lose confidence in yourself. To make them feel more comfortable we yarn18 (talk) with the women about family and their kids, and talk and play with the kids in the house. If they feel they need to apologise for ‘the mess’ we let them know that we have big families and lots of kids running around at our homes too. Before administering the Bayley III we explain to the mum18 what it is, why we do the assessment and let them know that we can make referrals to a child health nurse or paediatrician with the mother’s permission if need be. We also remind them there is no wrong or right in the Bayley III and that all babies grow differently. The mum is always involved. We ask a range of questions such as what they have noticed about their baby’s personality and development. The mother’s answers assist us in trying different ways to get accurate results for the assessment. A highlight when doing the Bayley III is seeing the mums smile and have that opportunity to take a quick break from life and just come admire their baby’s intelligence and tell us stories about how baby’s development has been improving over the last week or so.
18 Glossary of Australian and Aboriginal English terms: Yarning = Talking, storytelling; Mum = Mother; Bub, Bubba: Baby; Mob = A collective group, community and extended family; Our mob = Aboriginal people; Shame, shame job: Feeling embarrassed, degraded, or a loss of confidence; Duh! = Of course!.
3
Some have said they did not even know their baby could do that yet as they had not really had the time to sit down and watch baby play. ‘As a mother of a toddler, yarning with women about being a mother and hearing the stories they have to share about their birthing experience is what interests me the most about this research project,’ says Sarah. ‘Being new to Brisbane coming to the city from a small town and not having any family or connections here, I did not really think I was going to see so many similarities to home. But they face a lot of the same issues that we have back home in our community with addictions and mental health.’ 3.3. Conducting the survey interviews Yarning is a term commonly used by Aboriginal people to describe a conversation that includes story telling or exchange of information. Yarning is an informal, more relaxed way for us as researchers to communicate and build a connection with our participants in the study.15 Usually, just by yarning with the women we get all the same information as we would if we would read each questions out from the survey, if not more detailed! We feel like yarning brings out more emotion in the conversation than a standard question–response interview, creating more of a connection between us and the women which builds up that rapport. We feel this improves the quality of the data for the study because women feel more comfortable and explain their answers more. 3.3.1. Sensitive questions in the surveys Many women have reported financial difficulties. Some might say they have run out of money for food but they made sure the kids were fed, so the adults were going without to support their children. It is not uncommon for these women to seek donations from Vinnies and Salvation Army (charity organisations) to help them until their next pay. With some financial questions in the surveys, the women may feel uncomfortable answering and sometimes worry for their confidentiality. In this case we remind them it’s confidential, that we will not put their names on any information they give us during the interview and can move onto another question if they are still uncomfortable talking about it. Some women feel more comfortable answering the question generally, not as a reflection of their own personal circumstances. For example, one of the questions we ask is from the National Aboriginal and Torres Strait Islander Health Survey16 whether they could get $2000 within a week for something important. A common reply is ‘Could any of our mob18?’ or such to relate it back to the poverty and culture rather than themselves as a person to help them to be more confident in answering. 3.3.2. Housing There have been women that have been stressed to keep a roof over their families’ heads as they may have been blacklisted or on a waiting list that could be a few years long. Community housing gives them two years to get a house and others sometimes only 12 months then they need to find another place to stay. Although some are on a waiting list for other housing it still takes a while for them to be accepted and they need the bond within two to three days or they miss out and are taken off the list. Mums with little or no support are finding this difficult especially if they have children and are pregnant with a new bubba18 too. We have noticed that women are moving houses a lot during pregnancy – sometimes staying at hostels, staying with different friends and family – so we always make sure our contact details are up-to-date! 3.3.3. Health and wellbeing – mental health Another touchy subject that comes up in the surveys is the wellbeing and support questions. Women are usually aware that
Please cite this article in press as: S.D. Hickey, et al., Participatory action research opens doors: Mentoring Indigenous researchers to improve midwifery in urban Australia, Women Birth (2017), https://doi.org/10.1016/j.wombi.2017.10.011
G Model WOMBI 732 No. of Pages 6
4
S.D. Hickey et al. / Women and Birth xxx (2017) xxx–xxx
their answers might prompt us to ask if they would like extra support or referral but often refuse the offer for support and reassure us they are okay. Women generally, will yarn about what issues they have been experiencing such as feeling nervous, anxious, and depressed due to death in the family or problems with partner. On occasion they have even asked us to put a less concerning answer in the survey so it does not trigger a mental health referral. This can affect the accuracy of the data by underestimating the percentage of women in the study that might be affected by mental health issues. It also concerns us that they may not trust the health system with their information or see value in ‘getting help’. However, for most of the women who do trigger a mental health referral, more often than not, the women are already linked into their local Aboriginal Community Controlled Health Service and are receiving clinical support for this. Most mums are open to answering the questions and expanding on some of their answers. When we ask the question ‘Do you feel full of life?’ They giggle and say, ‘Duh!18 There is a baby/life inside me!’ Joking aside, not all women have a lot of support throughout their pregnancy and after bub18 is born. As this is an important and vulnerable time in mum’s life, and added pressure from going through a lot during their pregnancy, we feel it’s very important the women have access to community services. They have really opened our eyes to what is happening to people and how it affects families in many different ways. Mental health needs to be taken into consideration with any health related issue. Especially in Indigenous health, most general and chronic health related issues link back to our mental health and wellbeing. 3.3.4. Women’s stories We do encourage women to be honest by suggesting that their answers can help others and that it is confidential. We believe we are able to create rapport and understanding with the women, encouraging them to express their thoughts openly through both the surveys and through the stories they tell us. Conducting faceto-face interviews is a privilege for us and we love being out in the field with the women although we did not initially realise how challenging it could be for some people to discuss their views on health related behaviour and the quality of care they received or their previous experiences or personal issues. Some women in this study have openly shared their stories about: Stillbirth prior to current pregnancy and how they coped with the stress and grieving and the effects it has had on them mentally during this pregnancy. Ongoing cycle with Child Safety Services (Queensland’s government child protection and safeguarding agency), growing up in the care system and having a child taken from her care and feeling like her child/children can be taken from them and placed in care. From our observations, mums seem to be trying their best to do the right thing by their family and get themselves back on the right track. The impact a death of a close family member has had on their whole life. Some women have had more than one death in the family within a 12 month period, deaths in custody and some even requiring relocation out of Brisbane to be closer to family even if that meant leaving the security of a job and a house behind. Women often give us positive feedback on their journey through the Birthing in Our Community model of care and often compare the experience to previous births and can say that they felt a lot more supported through this model of care and having home visits from a midwife and an Indigenous health worker was an added bonus. Although at this stage we do not speak much to
the women’s partners, the women have said that the health workers and midwives do a great job at including the father of the baby in the appointments and offering the partner support (i.e. to quit smoking). All of the women report that the father of the baby is excited to have a new born on the way and that they want to do the best they can to support their partner and baby financially and emotionally. 3.4. What happens next The stories women share with us can at times feel like a burden. We feel we have an obligation to these women to ensure their stories are told and used to prompt improvements in the maternity services. We try not to take away the negative stories home in our mind. We write their stories in field notes and debrief confidentially with our supervisor and colleagues, or talk about it in our PAR meetings to get it off our chest. These women are inspiring: their resilience to live everyday as it comes, putting their children first and wearing a smile every day despite their circumstances. It helps us to acknowledge that they share these stories so that changes can be made to help support women with similar circumstances. We sometimes think back and ask ourselves, ‘Will we ever see these women again?’, and ‘we hope they are doing good and living healthy.’ Sarah considers, ‘A personal challenge for me when building rapport with the women is thinking about what happens when the research project is finished. What use do we make of all the stories the women have shared with us? Will the data be an accurate representation and reflection of their stories?’ This is why working in collaboration with the Aboriginal Community Controlled Health Services means that the findings can feed straight back into the service delivery and planning for our mob. We have recently presented the data findings from the first 100 surveys to the Birthing in Our Community Steering Committee and team members to give them an overview of what the women accessing their services have reported. Our data also helped secure funding to hire a full time Social Worker to be based with the Birthing in Our Community team. The IBUS study team have been discussing how we can use the women’s stories to educate health staff in the hospitals on cultural awareness. We are thinking of doing this through a qualitative component called ‘Tell My Story’. Here, we will ask participants if they are willing to share their pregnancy, birthing and parenting stories and be either video or audio recorded. Tell My Story will give the women an opportunity to be more involved in the research and be proud of the final production. 3.5. Reflection on our experience In the past six months working as research assistants, we have been introduced into a whole new world. We have learnt so much, including what we would like to do in the future. Being on the IBUS research team has given us the opportunity to explore maternity services, Aboriginal health services, and hear what women want from these services compared to what they are currently receiving from these services. Kayla says, ‘I have grown socially and mentally since becoming a research assistant. I enjoy doing the surveys with mums knowing what we aim to get out of it. I have learnt so much about many different things. I like thinking that the health services and model of care will be improved over time step by step for when I start my own family. I am more confident when introducing myself and the IBUS study to women and health staff than when I first started in this position. I have learnt more about this study and I still learn more and more about it every day whether it is from Sophie, Sarah or another person within the study.’
Please cite this article in press as: S.D. Hickey, et al., Participatory action research opens doors: Mentoring Indigenous researchers to improve midwifery in urban Australia, Women Birth (2017), https://doi.org/10.1016/j.wombi.2017.10.011
G Model WOMBI 732 No. of Pages 6
S.D. Hickey et al. / Women and Birth xxx (2017) xxx–xxx
‘This role has made me reflect back on my own birthing experience in a hospital through the mainstream sector and how it could have been done better’, says Sarah. ‘Fortunately I had the ongoing support of a Family Partnership program to give me all the appropriate information to prepare me for the birth. I see that there is room for improvement when it comes to birthing and supporting women in birthing.’ 3.6. Future direction Being new to health and working alongside midwives and the research team, we now have an idea of what careers we would like to pursue which would work towards building a better future for Aboriginal and Torres Strait Islander health care. Sarah would like to study midwifery in the future and wants to learn more about the benefits of natural birthing: ‘I would like to support women through their pregnancy journey and build their confidence to help prepare them to become strong, confident mothers to their newborn babies. I would like to see women feel more confident in their self to have natural labours without inductions or medical interventions when it is not needed. There needs to be more Aboriginal and Torres Strait Islander people employed as midwives and doctors. It’s great having Aboriginal Health Workers to assist the midwives and it makes women feel more comfortable with them present but receiving care directly from their own mob would make these women feel empowered and feel a sense of community and trust within their model of care.’ Kayla is also interested in working in Indigenous health and would like to study nursing in the future. ‘I love seeing mums at the hospital when bub has just been born. It’s good to see the mum’s happy with bub. I have never really had a solid answer for what I want to do in the future before but now I realise that I would like to work within the Indigenous Community as a Child Health Nurse. I am hoping to start studying next year at University.’ 4. Concluding reflections from the PAR team The senior PAR team members have found it a wonderful experience to mentor and watch the growth of the two research assistants. The ongoing PAR meetings have served as a ‘checkpoint’ to reflect upon what the research assistants have been encountering and what timely actions can be made to improve the IBUS study and also the midwifery services being evaluated. Even the process of writing this article together has been a positive example of active capacity building. Yvette says ‘As a female Aboriginal researcher, I have witnessed the research assistants develop as researchers and continue to grow as inspiring women. Both have brought their own unique talents to the role as well as attributes as strong Aboriginal women who are learning and contributing to the craft of research. The insights and maturity that they have shared adds a voice that cannot be captured in the traditional data collection methods. As a reader, you gain an insight into the importance of the relationship they have formed with participants and the commitment of ensuring the research is able to adequately capture the characteristics and voices of the mums. It is with excitement that I eagerly await the next chapter of their journey.’ Similar to a recent study in the experiences of Indigenous student midwifery students providing caseload care for Indigenous women,17 the senior PAR team members saw the satisfaction the research assistants experienced by ‘journeying’ with the women over their pregnancy, birth and early parenting journey, resulting in growth in confidence, strengthened identity and sense of purpose. The research assistants have been doing a tremendous job understanding the importance of getting the right story, ensuring that they reflect what the women are saying. This has meant the
5
quality of the data collected has been very strong, and importantly, this has allowed the team to lobby for extra funding to increase the support for women. Sue says, ‘seeing that they now both want to have careers as nurses and midwives, I will be very sad when they leave our team but is very professionally satisfying to me as I think that we have started them on a journey that will lead them into these careers which I think are the best jobs in the world! This means of course that they will never really leave us.’ As a team, we hope that this ‘good news story’ inspires other researcher groups to considering using PAR approaches to mentor young researchers and build capacity among the Indigenous health research workforce – an essential part to ‘closing the gap’ in health outcomes between Indigenous people and other Australians.1 Ethical statement Ethical approval for the Indigenous Birthing in an Urban Setting study was granted from the Mater Health Services Human Research Ethics Committee (HREC/15/MHS/24) on 15/04/2015, the University of Queensland’s Behavioural and Social Sciences Ethical Review Committee (No. 2015000624) on 27/04/2015, and by the Metro North Hospital and Health Service-Royal Brisbane and Women’s Hospital (HREC/15/MHS/24) on 07/07/2015. Acknowledgements This Partnership Project was supported by the National Health and Medical Research Council in Australia (Grant number APP1077036), the Mater Misericordiae Limited (Queensland, Australia), the Institute for Urban Indigenous Health, and the Aboriginal and Torres Strait Islander Community Health Service Brisbane Limited. We would like to thank Wardliparingga – South Australian Health & Medical Research Institute for the research masterclass training provided at the Institute for Urban Indigenous Health, and Dr Gabrielle Simcock for supervising the Bayley Assessments. We would like to thank and acknowledge the IBUS Investigator team and the Steering Committee for the Birthing in Our Community Program and the Aboriginal and Torres Strait Islander families and all of the staff who have contributed to, and participated in, the IBUS study. References 1. Kildea S, Tracy S, Sherwood J, Magick-Dennis F, Barclay L. Improving maternity services for Indigenous women in Australia: moving from policy to practice. Med J Aust 2016;205(8):374–9. 2. Bertilone C, McEvoy S, Gower D, Naylor N, Doyle J, Swift-Otero V. Elements of cultural competence in an Australian Aboriginal maternity program. Women Birth 2017;30(2):121–8. 3. Kildea S, Stapleton H, Murphy R, Low N, Gibbons K. The Murri clinic: a comparative retrospective study of an antenatal clinic developed for Aboriginal and Torres Strait Islander women. BMC Pregnancy Childbirth 2012;12:159–70. 4. Brown A, Middleton P, Fereday J, Pincombe J. Cultural safety and midwifery care for Aboriginal women —a phenomenological study. Women Birth 2016;29:196–202. 5. Corcoran P, Catling C, Homer C. Models of midwifery care for Indigenous women and babies: a meta-synthesis. Women Birth 2017;30:77–86. 6. Kildea S, Kruske S, Barclay L, Tracy S. ‘Closing the Gap’: how maternity services can contribute to reducing poor maternal infant health outcomes for Aboriginal and Torres Strait Islander women. Rural Remote Health 2010;10:1383–401. 7. Kildea S, Hickey S, Nelson C, Currie J, Carson A, Reynolds M, et al. Birthing on country (in our community): a case study of engaging stakeholders and developing a best practice Indigenous maternity service in an urban setting. Aust Health Rev 2017. doi:http://dx.doi.org/10.1071/AH16218 in press. 8. NHMRC. Road Map II: a strategic framework for improving the health of Aboriginal and Torres Strait Islander people through research. Canberra: National Health and Medical Research Council; 2010. 9. Brydon-Miller M, Greenwood D, Maguire P. Why action research? Action Res 2003;1(1):9–28.
Please cite this article in press as: S.D. Hickey, et al., Participatory action research opens doors: Mentoring Indigenous researchers to improve midwifery in urban Australia, Women Birth (2017), https://doi.org/10.1016/j.wombi.2017.10.011
G Model WOMBI 732 No. of Pages 6
6
S.D. Hickey et al. / Women and Birth xxx (2017) xxx–xxx
10. Smith L, Rosenzweig L, Schmidt M. Best practices in the reporting of participatory action research: embracing both the forest and the trees 1C7. Couns Psychol 2010;38(8):1115–38. 11. Liamputtong P. Participatory action research. Qualitative research methods. 4th ed. South Melbourne: Oxford University Press; 2013. p. 180–98. 12. Miller A, Massey P, Judd J, Kelly J, Durrheim D, Clough A, et al. Using a participatory action research framework to listen to Aboriginal and Torres Strait Islander people in Australia about pandemic influenza. Rural Remote Health 2015;15:1–10. 13. Kelly J. Is it Aboriginal friendly? Searching for ways of working in research and practice that support Aboriginal women. Contemp Nurse 2006;22(2):317–26.
14. Bayley N. Bayley scale of infant and toddler development (Bayley III). 3rd ed. San Antonio, Texas: Harcourt Assessments; 2006. 15. Bessarab D, Ng’andu B. Yarning about yarning as a legitimate method in indigenous research. Int J Crit Indigenous Stud 2010;3(1):37–50. 16. ABS. National Aboriginal and Torres Strait Islander health survey 2012–13: user’s guide. Canberra: Australian Bureau of Statistics; 2013. 17. West R, Gamble J, Kelly J, Milne T, Duffy E, Sidebotham M. Culturally capable and culturally safe: caseload care for Indigenous women by Indigenous midwifery students. Women Birth 2016;29:524–30.
Please cite this article in press as: S.D. Hickey, et al., Participatory action research opens doors: Mentoring Indigenous researchers to improve midwifery in urban Australia, Women Birth (2017), https://doi.org/10.1016/j.wombi.2017.10.011
Women and Birth xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
Women and Birth journal homepage: www.elsevier.com/locate/wombi
Participatory action research opens doors: Mentoring Indigenous researchers to improve midwifery in urban Australia Sophie D. Hickeya,* , Sarah-Jade Maidmenta , Kayla M. Heinemanna , Yvette L. Roea , Sue V. Kildeaa,b a Midwifery Research Unit, Mater Medical Research Institute-University of Queensland, Level 2, Aubigny Place, Raymond Tce, South Brisbane QLD 4101, Australia b School of Nursing, Midwifery and Social Work, University of Queensland, St Lucia, QLD 4072, Australia
A R T I C L E I N F O
A B S T R A C T
Article history: Received 15 February 2017 Received in revised form 20 October 2017 Accepted 25 October 2017 Available online xxx
Problem: There is increasing demand for capacity building among the Aboriginal and Torres Strait Islander (Indigenous) maternal and infant health workforce to improve health outcomes for mothers and babies; yet few studies describe the steps taken to mentor novice Indigenous researchers to contribute to creating a quality evidence-base in this space. Background: The Indigenous Birthing in an Urban Setting study is a partnership project aimed at improving maternity services for Indigenous families in South East Queensland. Aim: To describe our experience setting up a Participatory Action Research team to mentor two young Indigenous women as research assistants on the Indigenous Birthing in an Urban Setting study. Methods: Case study reflecting on the first six months. Findings: Participatory Action Research was a very effective method to actively mentor and engage all team members in reflective, collaborative research practice, resulting in positive changes for the maternity care service. The research assistants describe learning to conduct interviews and infant assessments, as well as gaining confidence to build rapport with families in the study. Reflecting on the stories shared by the women participating in the study has opened up a whole new world and interest in studying midwifery and child health after learning the difficulties and strengths of families during pregnancy and beyond. Discussion: We encourage others to use Participatory Action Research to enable capacity building in the Aboriginal and Torres Strait Islander midwifery workforce and in health research more broadly. © 2017 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.
Keywords: Aboriginal and Torres Strait Islander people Participatory Action Research Capacity building Midwifery Indigenous Health Services
Statement of significance
Problem or issue There is a need to build capacity among the Indigenous maternity workforce to ‘close the gap’ in maternal and infant health outcomes between Indigenous and other Australians.
What this paper adds This case study presents our experiences of successfully using a Participatory Action Research framework to mentor two young Indigenous women with no health or research experience to conduct high quality midwifery research. The initiative was so successful that these women now want to study nursing and midwifery.
What is already known Participatory Action Research is a valued by Indigenous people as an outcomes driven, inclusive collaborative research approach.
* Corresponding author. E-mail address: [email protected] (S.D. Hickey).
1. Introduction Conducting research can be a transformative experience, particularly for those new to the field. With sufficient training and appropriate mentorship, enthusiastic community members and peer-interviewers can become empowered and critically reflective researchers. Research capacity building among the
https://doi.org/10.1016/j.wombi.2017.10.011 1871-5192/© 2017 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: S.D. Hickey, et al., Participatory action research opens doors: Mentoring Indigenous researchers to improve midwifery in urban Australia, Women Birth (2017), https://doi.org/10.1016/j.wombi.2017.10.011
G Model WOMBI 732 No. of Pages 6
2
S.D. Hickey et al. / Women and Birth xxx (2017) xxx–xxx
Aboriginal and Torres Strait Islander (here after referred to as Indigenous) maternal and infant health workforce is vital to ensure best practice, culturally relevant, evidence-based maternity care.1 This case study presents our experiences of successfully using a Participatory Action Research (PAR) framework on the Indigenous Birthing in an Urban Setting (IBUS) study to mentor two young Indigenous women with no previous health or research experience as research assistants to conduct high quality midwifery research. Given the increasing demand of specialised Indigenous maternity care services to improve Indigenous maternal and infant health outcomes,2–6 we hope that this example encourages others to nurture the growing Indigenous workforce using PAR approaches as we strive towards improving capacity for Indigenous-led midwifery research and health service provision. 2. Study background The IBUS study is a five-year prospective mixed-methods longitudinal cohort study that commenced in 2015. It was developed in partnership with two key Aboriginal Community Controlled Health Organisations that service the Brisbane region: the Institute for Urban Indigenous Health and the Aboriginal and Torres Strait Islander Community Health Service, Brisbane Limited; and Mater Mothers Hospital which provides maternity care to approximately 10,000 birthing women a year. The study’s aim is to identify improvements needed for maternity services available to women having Aboriginal and/or Torres Strait Islander babies and birthing in South East Queensland.7 Pregnant women are recruited at the Mater Mothers Hospital and The Royal Brisbane and Women's Hospital and are followed up until six months postnatal. Both hospitals run a Midwifery Group Practice for women having Aboriginal and Torres Strait Islander babies, named Birthing in Our Community and Ngarrama Indigenous Maternity Service. Through these services, women receive care from a primary midwife with the support of an Indigenous health worker. Birthing in Our Community is a partnership between the Mater Mothers Hospital, the Institute for Urban Indigenous Health and the Aboriginal and Torres Strait Islander Community Health Service, Brisbane Ltd, while Ngarrama is delivered through Queensland Health. Embedded in the IBUS study is an Indigenous workforce capacity building component which includes student midwifery cadetships, ongoing career development for Maternal and Infant Health Workers, and pertinent to this paper, the training of Indigenous research assistants (co-researchers) to undertake recruitment and data collection according to Good Clinical Practice Guidelines but also in a culturally safe and supportive manner. 2.1. Improving the health of Aboriginal and Torres Strait Islander people through Participatory Action Research Australia’s National Health and Medical Research Council’s Roadmap II8 provides strategic direction for Indigenous health research and emphasises the need to increase participation and development of research skills of the Indigenous workforce. PAR is a unique methodological approach that can inspire novice researchers through the power of research to enact sustained positive change in health service provision and planning.9 It has an emancipatory and empowerment focus in prioritising ‘local perspectives, needs and knowledge . . . through collaborations with community members throughout the research process’.10 Central importance is given to a shared commitment to change and a genuine partnered approach of ‘knowing by doing’ between the researcher and the researched11 (indeed these roles become blurred). Through its regular, reflective and responsive cycle to ‘Plan, Act, Reflect, Evaluate – Repeat!’ PAR allows for appropriate, timely and context-specific actions to be taken in both the research
design and service implementation. Study design can be flexible and can employ multi methods as appropriate, with interpretations of the data cross-checked through triangulation.11 PAR is a valued research method in Indigenous health for its capacity to collaboratively engage the Indigenous community in research.12,13 Involving Indigenous people at every stage of Indigenous health research is essential if the research is to be both meaningful, relevant and useful to effecting positive change in health outcomes among this population. 2.2. The Participatory Action Research team In May 2016, the authors formed a Participatory Action Research team that meets monthly to discuss and reflect on progress, challenges and strengths of the study, the maternity services being evaluated, and the women’s stories. The team shares their field notes and experiences so that both novice and senior team members can learn together and take positive actions to improve the study or the midwifery services directly. Yvette Roe is an early career researcher and a Njikena Jawuru woman from the Kimberley region, Western Australia, and provides mentorship for the PAR team. Sue Kildea is the Chief Investigator of the IBUS study who has extensive experience with using PAR methods for health service change to improve maternal and infant health outcomes. Sophie Hickey is an early career researcher with a social science and public health background and manages the day-to-day running of the IBUS study, including training and supervising the research assistants. Sarah Maidment and Kayla Heinemannare Indigenous research assistants for the IBUS study who recruit, follow-up and interview pregnant and postnatal women in the study. Ethics and governance approvals for the IBUS study were granted by the relevant sites. Prior to commencing their role as research assistants six months ago, both Sarah and Kayla had no previous formal experience in research. In the following section, Sarah and Kayla reflect on their experiences working with the IBUS Study. To privilege their voices, the section has been written in first person. 3. Sarah and Kayla’s experience We began as research assistants on the IBUS Study in May 2016. Kayla’s family is from the Bunjalung region from Byron Bay and she was born and raised around Brisbane. Sarah is an Arrernte woman from Alice Springs now living in Brisbane. On how we each came to this role, Kayla explains, ‘I came from hospitality to research unexpectedly as a recommendation from a relative who believed I would be great in the role. I have not looked back and have enjoyed the experience every step of the way.’ Sarah had been working in tourism and adds, ‘What interested me in this role was to talk to women and hear their stories; as a mother I feel like I can relate to these women and I liked the idea that I can give them the opportunity to reflect on their birthing experience. I think that is an important part of the birthing journey that people do not always have the opportunity to do.’ 3.1. Research training and professional development To prepare us for field work, we were trained internally on interviewing techniques, consenting procedures, and learnt about our role within the research study and its many sub-studies. With Sophie, we role-played many practice surveys and addressed what we would do in challenging hypothetical situations, including risk assessments (e.g. suicidal risk or self-harm) and referral processes. As part of our professional development training, we attended a two day Research Masterclass hosted by the Institute for Urban Indigenous Health and presented by Wardliparingga, South
Please cite this article in press as: S.D. Hickey, et al., Participatory action research opens doors: Mentoring Indigenous researchers to improve midwifery in urban Australia, Women Birth (2017), https://doi.org/10.1016/j.wombi.2017.10.011
G Model WOMBI 732 No. of Pages 6
S.D. Hickey et al. / Women and Birth xxx (2017) xxx–xxx
Australian Health & Medical Research Institute. The topics over the two days included: introduction to research, how to form a research question and how to create a research study around your research question, as well as an overview of ethics in research. The masterclass helped us to understand how research evolves from a research question and findings can be implemented into health services. Sue talked us through research and the difference between qualitative and quantitative research. She gave a presentation on her PhD to give us an idea on what participatory action research in the remote Indigenous setting looked like and explained the IBUS research framework and where we fit in before we commenced field work. We also attended a two day workshop on the Bayley Scale of Infant and Toddler Development – Third Edition (Bayley III)14 and are now trained on administering the Bayley III on the infants in the study when they are about six months old. The Bayley III is a comprehensive and interactive tool used to assess infant and toddler development, focusing on cognitive, language, and motor skills.13 It was originally developed using an American population of children to create the norms of infant and toddler developmental milestones. The purpose of administering the Bayley III in this study is to compare the norms from the United States with scores from urban Indigenous Australian infants to determine if this scale is appropriate and accurate to use in this setting. 3.2. Conducting infant assessments With ongoing supervision from Dr Gabrielle Simcock, a PostDoctoral Research Fellow in our Unit who specialises in infant growth and development, we conduct the Bayley III and surveys in the women’s homes if they have invited us. Going out on home visits together and supporting each other to accurately administer the Bayley III and conduct the interview makes us feel more confident doing the job. It is important to us to make the mothers feel comfortable with us being there. Sarah admits, ‘On my first few times administering the Bayley III assessment, I was nervous’. We do not want the women to feel judged as a parent, based on their infant’s development. Or ‘shame’18 to have us researchers at their house – some women might not have even met us in person before allowing us to visit. Shame or shame job is the term used by Aboriginal people to describe a feeling or situation that has made you really embarrassed. Shame can make you feel degraded and lose confidence in yourself. To make them feel more comfortable we yarn18 (talk) with the women about family and their kids, and talk and play with the kids in the house. If they feel they need to apologise for ‘the mess’ we let them know that we have big families and lots of kids running around at our homes too. Before administering the Bayley III we explain to the mum18 what it is, why we do the assessment and let them know that we can make referrals to a child health nurse or paediatrician with the mother’s permission if need be. We also remind them there is no wrong or right in the Bayley III and that all babies grow differently. The mum is always involved. We ask a range of questions such as what they have noticed about their baby’s personality and development. The mother’s answers assist us in trying different ways to get accurate results for the assessment. A highlight when doing the Bayley III is seeing the mums smile and have that opportunity to take a quick break from life and just come admire their baby’s intelligence and tell us stories about how baby’s development has been improving over the last week or so.
18 Glossary of Australian and Aboriginal English terms: Yarning = Talking, storytelling; Mum = Mother; Bub, Bubba: Baby; Mob = A collective group, community and extended family; Our mob = Aboriginal people; Shame, shame job: Feeling embarrassed, degraded, or a loss of confidence; Duh! = Of course!.
3
Some have said they did not even know their baby could do that yet as they had not really had the time to sit down and watch baby play. ‘As a mother of a toddler, yarning with women about being a mother and hearing the stories they have to share about their birthing experience is what interests me the most about this research project,’ says Sarah. ‘Being new to Brisbane coming to the city from a small town and not having any family or connections here, I did not really think I was going to see so many similarities to home. But they face a lot of the same issues that we have back home in our community with addictions and mental health.’ 3.3. Conducting the survey interviews Yarning is a term commonly used by Aboriginal people to describe a conversation that includes story telling or exchange of information. Yarning is an informal, more relaxed way for us as researchers to communicate and build a connection with our participants in the study.15 Usually, just by yarning with the women we get all the same information as we would if we would read each questions out from the survey, if not more detailed! We feel like yarning brings out more emotion in the conversation than a standard question–response interview, creating more of a connection between us and the women which builds up that rapport. We feel this improves the quality of the data for the study because women feel more comfortable and explain their answers more. 3.3.1. Sensitive questions in the surveys Many women have reported financial difficulties. Some might say they have run out of money for food but they made sure the kids were fed, so the adults were going without to support their children. It is not uncommon for these women to seek donations from Vinnies and Salvation Army (charity organisations) to help them until their next pay. With some financial questions in the surveys, the women may feel uncomfortable answering and sometimes worry for their confidentiality. In this case we remind them it’s confidential, that we will not put their names on any information they give us during the interview and can move onto another question if they are still uncomfortable talking about it. Some women feel more comfortable answering the question generally, not as a reflection of their own personal circumstances. For example, one of the questions we ask is from the National Aboriginal and Torres Strait Islander Health Survey16 whether they could get $2000 within a week for something important. A common reply is ‘Could any of our mob18?’ or such to relate it back to the poverty and culture rather than themselves as a person to help them to be more confident in answering. 3.3.2. Housing There have been women that have been stressed to keep a roof over their families’ heads as they may have been blacklisted or on a waiting list that could be a few years long. Community housing gives them two years to get a house and others sometimes only 12 months then they need to find another place to stay. Although some are on a waiting list for other housing it still takes a while for them to be accepted and they need the bond within two to three days or they miss out and are taken off the list. Mums with little or no support are finding this difficult especially if they have children and are pregnant with a new bubba18 too. We have noticed that women are moving houses a lot during pregnancy – sometimes staying at hostels, staying with different friends and family – so we always make sure our contact details are up-to-date! 3.3.3. Health and wellbeing – mental health Another touchy subject that comes up in the surveys is the wellbeing and support questions. Women are usually aware that
Please cite this article in press as: S.D. Hickey, et al., Participatory action research opens doors: Mentoring Indigenous researchers to improve midwifery in urban Australia, Women Birth (2017), https://doi.org/10.1016/j.wombi.2017.10.011
G Model WOMBI 732 No. of Pages 6
4
S.D. Hickey et al. / Women and Birth xxx (2017) xxx–xxx
their answers might prompt us to ask if they would like extra support or referral but often refuse the offer for support and reassure us they are okay. Women generally, will yarn about what issues they have been experiencing such as feeling nervous, anxious, and depressed due to death in the family or problems with partner. On occasion they have even asked us to put a less concerning answer in the survey so it does not trigger a mental health referral. This can affect the accuracy of the data by underestimating the percentage of women in the study that might be affected by mental health issues. It also concerns us that they may not trust the health system with their information or see value in ‘getting help’. However, for most of the women who do trigger a mental health referral, more often than not, the women are already linked into their local Aboriginal Community Controlled Health Service and are receiving clinical support for this. Most mums are open to answering the questions and expanding on some of their answers. When we ask the question ‘Do you feel full of life?’ They giggle and say, ‘Duh!18 There is a baby/life inside me!’ Joking aside, not all women have a lot of support throughout their pregnancy and after bub18 is born. As this is an important and vulnerable time in mum’s life, and added pressure from going through a lot during their pregnancy, we feel it’s very important the women have access to community services. They have really opened our eyes to what is happening to people and how it affects families in many different ways. Mental health needs to be taken into consideration with any health related issue. Especially in Indigenous health, most general and chronic health related issues link back to our mental health and wellbeing. 3.3.4. Women’s stories We do encourage women to be honest by suggesting that their answers can help others and that it is confidential. We believe we are able to create rapport and understanding with the women, encouraging them to express their thoughts openly through both the surveys and through the stories they tell us. Conducting faceto-face interviews is a privilege for us and we love being out in the field with the women although we did not initially realise how challenging it could be for some people to discuss their views on health related behaviour and the quality of care they received or their previous experiences or personal issues. Some women in this study have openly shared their stories about: Stillbirth prior to current pregnancy and how they coped with the stress and grieving and the effects it has had on them mentally during this pregnancy. Ongoing cycle with Child Safety Services (Queensland’s government child protection and safeguarding agency), growing up in the care system and having a child taken from her care and feeling like her child/children can be taken from them and placed in care. From our observations, mums seem to be trying their best to do the right thing by their family and get themselves back on the right track. The impact a death of a close family member has had on their whole life. Some women have had more than one death in the family within a 12 month period, deaths in custody and some even requiring relocation out of Brisbane to be closer to family even if that meant leaving the security of a job and a house behind. Women often give us positive feedback on their journey through the Birthing in Our Community model of care and often compare the experience to previous births and can say that they felt a lot more supported through this model of care and having home visits from a midwife and an Indigenous health worker was an added bonus. Although at this stage we do not speak much to
the women’s partners, the women have said that the health workers and midwives do a great job at including the father of the baby in the appointments and offering the partner support (i.e. to quit smoking). All of the women report that the father of the baby is excited to have a new born on the way and that they want to do the best they can to support their partner and baby financially and emotionally. 3.4. What happens next The stories women share with us can at times feel like a burden. We feel we have an obligation to these women to ensure their stories are told and used to prompt improvements in the maternity services. We try not to take away the negative stories home in our mind. We write their stories in field notes and debrief confidentially with our supervisor and colleagues, or talk about it in our PAR meetings to get it off our chest. These women are inspiring: their resilience to live everyday as it comes, putting their children first and wearing a smile every day despite their circumstances. It helps us to acknowledge that they share these stories so that changes can be made to help support women with similar circumstances. We sometimes think back and ask ourselves, ‘Will we ever see these women again?’, and ‘we hope they are doing good and living healthy.’ Sarah considers, ‘A personal challenge for me when building rapport with the women is thinking about what happens when the research project is finished. What use do we make of all the stories the women have shared with us? Will the data be an accurate representation and reflection of their stories?’ This is why working in collaboration with the Aboriginal Community Controlled Health Services means that the findings can feed straight back into the service delivery and planning for our mob. We have recently presented the data findings from the first 100 surveys to the Birthing in Our Community Steering Committee and team members to give them an overview of what the women accessing their services have reported. Our data also helped secure funding to hire a full time Social Worker to be based with the Birthing in Our Community team. The IBUS study team have been discussing how we can use the women’s stories to educate health staff in the hospitals on cultural awareness. We are thinking of doing this through a qualitative component called ‘Tell My Story’. Here, we will ask participants if they are willing to share their pregnancy, birthing and parenting stories and be either video or audio recorded. Tell My Story will give the women an opportunity to be more involved in the research and be proud of the final production. 3.5. Reflection on our experience In the past six months working as research assistants, we have been introduced into a whole new world. We have learnt so much, including what we would like to do in the future. Being on the IBUS research team has given us the opportunity to explore maternity services, Aboriginal health services, and hear what women want from these services compared to what they are currently receiving from these services. Kayla says, ‘I have grown socially and mentally since becoming a research assistant. I enjoy doing the surveys with mums knowing what we aim to get out of it. I have learnt so much about many different things. I like thinking that the health services and model of care will be improved over time step by step for when I start my own family. I am more confident when introducing myself and the IBUS study to women and health staff than when I first started in this position. I have learnt more about this study and I still learn more and more about it every day whether it is from Sophie, Sarah or another person within the study.’
Please cite this article in press as: S.D. Hickey, et al., Participatory action research opens doors: Mentoring Indigenous researchers to improve midwifery in urban Australia, Women Birth (2017), https://doi.org/10.1016/j.wombi.2017.10.011
G Model WOMBI 732 No. of Pages 6
S.D. Hickey et al. / Women and Birth xxx (2017) xxx–xxx
‘This role has made me reflect back on my own birthing experience in a hospital through the mainstream sector and how it could have been done better’, says Sarah. ‘Fortunately I had the ongoing support of a Family Partnership program to give me all the appropriate information to prepare me for the birth. I see that there is room for improvement when it comes to birthing and supporting women in birthing.’ 3.6. Future direction Being new to health and working alongside midwives and the research team, we now have an idea of what careers we would like to pursue which would work towards building a better future for Aboriginal and Torres Strait Islander health care. Sarah would like to study midwifery in the future and wants to learn more about the benefits of natural birthing: ‘I would like to support women through their pregnancy journey and build their confidence to help prepare them to become strong, confident mothers to their newborn babies. I would like to see women feel more confident in their self to have natural labours without inductions or medical interventions when it is not needed. There needs to be more Aboriginal and Torres Strait Islander people employed as midwives and doctors. It’s great having Aboriginal Health Workers to assist the midwives and it makes women feel more comfortable with them present but receiving care directly from their own mob would make these women feel empowered and feel a sense of community and trust within their model of care.’ Kayla is also interested in working in Indigenous health and would like to study nursing in the future. ‘I love seeing mums at the hospital when bub has just been born. It’s good to see the mum’s happy with bub. I have never really had a solid answer for what I want to do in the future before but now I realise that I would like to work within the Indigenous Community as a Child Health Nurse. I am hoping to start studying next year at University.’ 4. Concluding reflections from the PAR team The senior PAR team members have found it a wonderful experience to mentor and watch the growth of the two research assistants. The ongoing PAR meetings have served as a ‘checkpoint’ to reflect upon what the research assistants have been encountering and what timely actions can be made to improve the IBUS study and also the midwifery services being evaluated. Even the process of writing this article together has been a positive example of active capacity building. Yvette says ‘As a female Aboriginal researcher, I have witnessed the research assistants develop as researchers and continue to grow as inspiring women. Both have brought their own unique talents to the role as well as attributes as strong Aboriginal women who are learning and contributing to the craft of research. The insights and maturity that they have shared adds a voice that cannot be captured in the traditional data collection methods. As a reader, you gain an insight into the importance of the relationship they have formed with participants and the commitment of ensuring the research is able to adequately capture the characteristics and voices of the mums. It is with excitement that I eagerly await the next chapter of their journey.’ Similar to a recent study in the experiences of Indigenous student midwifery students providing caseload care for Indigenous women,17 the senior PAR team members saw the satisfaction the research assistants experienced by ‘journeying’ with the women over their pregnancy, birth and early parenting journey, resulting in growth in confidence, strengthened identity and sense of purpose. The research assistants have been doing a tremendous job understanding the importance of getting the right story, ensuring that they reflect what the women are saying. This has meant the
5
quality of the data collected has been very strong, and importantly, this has allowed the team to lobby for extra funding to increase the support for women. Sue says, ‘seeing that they now both want to have careers as nurses and midwives, I will be very sad when they leave our team but is very professionally satisfying to me as I think that we have started them on a journey that will lead them into these careers which I think are the best jobs in the world! This means of course that they will never really leave us.’ As a team, we hope that this ‘good news story’ inspires other researcher groups to considering using PAR approaches to mentor young researchers and build capacity among the Indigenous health research workforce – an essential part to ‘closing the gap’ in health outcomes between Indigenous people and other Australians.1 Ethical statement Ethical approval for the Indigenous Birthing in an Urban Setting study was granted from the Mater Health Services Human Research Ethics Committee (HREC/15/MHS/24) on 15/04/2015, the University of Queensland’s Behavioural and Social Sciences Ethical Review Committee (No. 2015000624) on 27/04/2015, and by the Metro North Hospital and Health Service-Royal Brisbane and Women’s Hospital (HREC/15/MHS/24) on 07/07/2015. Acknowledgements This Partnership Project was supported by the National Health and Medical Research Council in Australia (Grant number APP1077036), the Mater Misericordiae Limited (Queensland, Australia), the Institute for Urban Indigenous Health, and the Aboriginal and Torres Strait Islander Community Health Service Brisbane Limited. We would like to thank Wardliparingga – South Australian Health & Medical Research Institute for the research masterclass training provided at the Institute for Urban Indigenous Health, and Dr Gabrielle Simcock for supervising the Bayley Assessments. We would like to thank and acknowledge the IBUS Investigator team and the Steering Committee for the Birthing in Our Community Program and the Aboriginal and Torres Strait Islander families and all of the staff who have contributed to, and participated in, the IBUS study. References 1. Kildea S, Tracy S, Sherwood J, Magick-Dennis F, Barclay L. Improving maternity services for Indigenous women in Australia: moving from policy to practice. Med J Aust 2016;205(8):374–9. 2. Bertilone C, McEvoy S, Gower D, Naylor N, Doyle J, Swift-Otero V. Elements of cultural competence in an Australian Aboriginal maternity program. Women Birth 2017;30(2):121–8. 3. Kildea S, Stapleton H, Murphy R, Low N, Gibbons K. The Murri clinic: a comparative retrospective study of an antenatal clinic developed for Aboriginal and Torres Strait Islander women. BMC Pregnancy Childbirth 2012;12:159–70. 4. Brown A, Middleton P, Fereday J, Pincombe J. Cultural safety and midwifery care for Aboriginal women —a phenomenological study. Women Birth 2016;29:196–202. 5. Corcoran P, Catling C, Homer C. Models of midwifery care for Indigenous women and babies: a meta-synthesis. Women Birth 2017;30:77–86. 6. Kildea S, Kruske S, Barclay L, Tracy S. ‘Closing the Gap’: how maternity services can contribute to reducing poor maternal infant health outcomes for Aboriginal and Torres Strait Islander women. Rural Remote Health 2010;10:1383–401. 7. Kildea S, Hickey S, Nelson C, Currie J, Carson A, Reynolds M, et al. Birthing on country (in our community): a case study of engaging stakeholders and developing a best practice Indigenous maternity service in an urban setting. Aust Health Rev 2017. doi:http://dx.doi.org/10.1071/AH16218 in press. 8. NHMRC. Road Map II: a strategic framework for improving the health of Aboriginal and Torres Strait Islander people through research. Canberra: National Health and Medical Research Council; 2010. 9. Brydon-Miller M, Greenwood D, Maguire P. Why action research? Action Res 2003;1(1):9–28.
Please cite this article in press as: S.D. Hickey, et al., Participatory action research opens doors: Mentoring Indigenous researchers to improve midwifery in urban Australia, Women Birth (2017), https://doi.org/10.1016/j.wombi.2017.10.011
G Model WOMBI 732 No. of Pages 6
6
S.D. Hickey et al. / Women and Birth xxx (2017) xxx–xxx
10. Smith L, Rosenzweig L, Schmidt M. Best practices in the reporting of participatory action research: embracing both the forest and the trees 1C7. Couns Psychol 2010;38(8):1115–38. 11. Liamputtong P. Participatory action research. Qualitative research methods. 4th ed. South Melbourne: Oxford University Press; 2013. p. 180–98. 12. Miller A, Massey P, Judd J, Kelly J, Durrheim D, Clough A, et al. Using a participatory action research framework to listen to Aboriginal and Torres Strait Islander people in Australia about pandemic influenza. Rural Remote Health 2015;15:1–10. 13. Kelly J. Is it Aboriginal friendly? Searching for ways of working in research and practice that support Aboriginal women. Contemp Nurse 2006;22(2):317–26.
14. Bayley N. Bayley scale of infant and toddler development (Bayley III). 3rd ed. San Antonio, Texas: Harcourt Assessments; 2006. 15. Bessarab D, Ng’andu B. Yarning about yarning as a legitimate method in indigenous research. Int J Crit Indigenous Stud 2010;3(1):37–50. 16. ABS. National Aboriginal and Torres Strait Islander health survey 2012–13: user’s guide. Canberra: Australian Bureau of Statistics; 2013. 17. West R, Gamble J, Kelly J, Milne T, Duffy E, Sidebotham M. Culturally capable and culturally safe: caseload care for Indigenous women by Indigenous midwifery students. Women Birth 2016;29:524–30.
Please cite this article in press as: S.D. Hickey, et al., Participatory action research opens doors: Mentoring Indigenous researchers to improve midwifery in urban Australia, Women Birth (2017), https://doi.org/10.1016/j.wombi.2017.10.011