Reframing spaces by building relationships: community collaborative participatory action research with Aboriginal mothers in prison

Developing and evaluating Birthing on Country services for First Nations Australians: the Building On Our Strengths (BOOSt) prospective mixed methods birth cohort study protocol

BACKGROUND

With the impact of over two centuries of colonisation in Australia, First Nations families experience a disproportionate burden of adverse pregnancy and birthing outcomes. First Nations mothers are 3-5 times more likely than other mothers to experience maternal mortality; babies are 2-3 times more likely to be born preterm, low birth weight or not to survive their first year. 'Birthing on Country' incorporates a multiplicity of interpretations but conveys a resumption of maternity services in First Nations Communities with Community governance for the best start to life. Redesigned services offer women and families integrated, holistic care, including carer continuity from primary through tertiary services; services coordination and quality care including safe and supportive spaces. The overall aim of Building On Our Strengths (BOOSt) is to facilitate and assess Birthing on Country expansion into two settings - urban and rural; with scale-up to include First Nations-operated birth centres. This study will build on our team's earlier work - a Birthing on Country service established and evaluated in an urban setting, that reported significant perinatal (and organisational) benefits, including a 37% reduction in preterm births, among other improvements.

METHODS

Using community-based, participatory action research, we will collaborate to develop, implement and evaluate new Birthing on Country care models. We will conduct a mixed-methods, prospective birth cohort study in two settings, comparing outcomes for women having First Nations babies with historical controls. Our analysis of feasibility, acceptability, clinical and cultural safety, effectiveness and cost, will use data including (i) women's experiences collected through longitudinal surveys (three timepoints) and yarning interviews; (ii) clinical records; (iii) staff and stakeholder views and experiences; (iv) field notes and meeting minutes; and (v) costs data. The study includes a process, impact and outcome evaluation of this complex health services innovation.

DISCUSSION

Birthing on Country applies First Nations governance and cultural safety strategies to support optimum maternal, infant, and family health and wellbeing. Women's experiences, perinatal outcomes, costs and other operational implications will be reported for Communities, service providers, policy advisors, and for future scale-up.

TRIAL REGISTRATION

Australia & New Zealand Clinical Trial Registry # ACTRN12620000874910 (2 September 2020).

Recasting Jung Through an Indigenist Approach to Deepen Shared Knowledges of Well-being and Healing on Australian Soils: Protocol for a Qualitative Landscape Research Study

BACKGROUND

The colonization of Australia is responsible for complex layers of trauma for the First Nations peoples of the continent. First Nations Australians' well-being is irrevocably tied to the well-being of the land. The application of a landscape-based approach to collaborative research shows promise in enabling genuine relationships that yield rich and informative data. However, there is a lack of practical evidence in the field of landscape research-research tied to First Nations Australians' worldviews of landscape.

OBJECTIVE

This study aims to deepen shared knowledges of well-being and healing on Australian soils. We aim to examine ritual co-design as a novel method for deepening these shared knowledges.

METHODS

This research comprises a qualitative and participatory action research design operationalized through an Indigenist approach. It is a 2-phase project that is co-designed with First Nations Australians. Phase 1 of this project is a relational study that endeavors to deepen the theory underpinning the project, alongside the development of meaningful and reciprocal community connections. Phase 2 is a series of 3 participatory action research cycles to co-design a new communal ritual. This process seeks to privilege First Nations Australians' voices and ways of knowing, which are themselves communal, ritual, and symbolic. The framework developed by psychiatrist Carl Jung informs the psychological nature of the enquiry. An Indigenist approach to landscape research recasts the Jungian frame to enable a culturally safe, context-specific, and landscape-based method of qualitative research.

RESULTS

The research is in the preliminary stages of participant recruitment. It is expected that data collection will commence in late 2022.

CONCLUSIONS

It is expected that this qualitative and co-designed project will strengthen the cross-cultural co-designer relationships and that the data gathered from these relationships, and the accompanying practical outcomes, will provide new insight into the interaction between human and landscape well-being. The field of landscape research is in an embryonic phase. This new field is embedded in the understanding that First Nations Australians' well-being is irrevocably tied to the well-being of the land, and this study seeks to build on this evidence base. A strength of this research is the relational methodology, in which First Nations Peoples' needs and desires will inform future research directions. It is limited by its context specific nature; however, it is expected that findings will be usable in guiding future research directions in the multidisciplinary field of landscape research.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/36328.

A Comprehensive Review of Optimal Approaches to Co-Design in Health with First Nations Australians

BACKGROUND

Australia's social, structural, and political context, together with the continuing impact of colonisation, perpetuates health care and outcome disparities for First Nations Australians. A new approach led by First Nations Australians is required to address these disparities. Co-design is emerging as a valued method for First Nations Australian communities to drive change in health policy and practice to better meet their needs and priorities. However, it is critical that co-design processes and outcomes are culturally safe and effective. Aims: This project aimed to identify the current evidence around optimal approaches to co-design in health with First Nations Australians.

METHODS

First Nations Australian co-led team conducted a comprehensive review to identify peer-reviewed and grey literature reporting the application of co-design in health-related areas by and with First Nations Australians. A First Nations Co-Design Working Group (FNCDWG) was established to guide this work and team.A Collaborative Yarning Methodology (CYM) was used to conduct a thematic analysis of the included literature.

RESULTS

After full-text screening, 99 studies were included. Thematic analysis elicited the following six key themes, which included 28 practical sub-themes, relevant to co-design in health with First Nations Australians: First Nations Australians leadership; Culturally grounded approach; Respect; Benefit to First Nations communities; Inclusive partnerships; and Evidence-based decision making.

CONCLUSION

The findings of this review provide a valuable snapshot of the existing evidence to be used as a starting point to guide appropriate and effective applications of co-design in health with First Nations Australians.

Appraising community driven health research with Aboriginal and Torres Strait Islander communities: a scoping review using the Aboriginal and Torres Strait Islander Quality Appraisal Tool

Most research involving Aboriginal and Torres Strait Islander peoples has been conducted by non-Indigenous people and has not been a positive experience for many Aboriginal and Torres Strait Islander communities. This scoping review maps approaches to health research involving Aboriginal and Torres Strait Islander peoples and communities in Australia from the last two decades. A literature search found 198 papers, of which 34 studies met the inclusion criteria. The Aboriginal and Torres Strait Islander Quality Appraisal Tool was then used to map the quality of the reported community driven research. The Quality Appraisal Tool privileges, Aboriginal and Torres Strait Islander people's epistemologies and ethical research governance. The findings reported on strengths and identified areas for improvement in reporting community driven research.

Patient and public involvement (PPI) in prisons: the involvement of people living in prison in the research process - a systematic scoping review

BACKGROUND

Patient and Public Involvement (PPI) in health and social care research is increasingly prevalent and is promoted in policy as a means of improving the validity of research. This also applies to people living in prison and using social care services. Whilst evidence for the effectiveness of PPI was limited and reviews of its application in prisons were not found, the infancy of the evidence base and moral and ethical reasons for involvement mean that PPI continues to be advocated in the community and in prisons.

OBJECTIVES

To conduct a review of the literature regarding the involvement of people or persons living in prison (PLiP) in health and social care research focused on: (i) aims; (ii) types of involvement; (iii) evaluations and findings; (iv) barriers and solutions; and (v) feasibility of undertaking a systematic review.

METHODS

A systematic scoping review was undertaken following Arksey and O'Malley's (International Journal of Social Research Methodology 8: 19-32, 2005) five-stage framework. A comprehensive search was conducted involving ten electronic databases up until December 2020 using patient involvement and context related search terms. A review-specific spreadsheet was created following the PICO formula, and a narrative synthesis approach was taken to answer the research questions. PRISMA guidelines were followed in reporting.

RESULTS

39 papers were selected for inclusion in the review. The majority of these took a 'participatory' approach to prisoner involvement, which occurred at most stages during the research process except for more 'higher' level research operations (funding applications and project management), and only one study was led by PLiPs. Few studies involved an evaluation of the involvement of PLiP, and this was mostly PLiP or researcher reflections without formal or independent analysis, and largely reported a positive impact. Barriers to the involvement of PLiP coalesced around power differences and prison bureaucracy.

CONCLUSION

Given the very high risk of bias arising from the available 'evaluations', it was not possible to derive firm conclusions about the effectiveness of PLiP involvement in the research process. In addition, given the state of the evidence base, it was felt that a systematic review would not be feasible until more evaluations were undertaken using a range of methodologies to develop the field further.

Directions for research practice in decolonising methodologies: Contending with paradox

The complex nature of colonisation presents with the potential for paradoxes in decolonising approaches, hence, fixed conventions and methods are discouraged. In this way, decolonising methodologies concerns interrogating dominant conventions in research that have typically excluded alternative ways of knowing from academia. This raises concern about the issue of breaking conventions, when it is potentially difficult to realise that one is depending upon them. An incremental approach to the research process and subsequent knowledge generated provides opportunity to challenge the conventions that typically dictate research praxis. In addition, fostering epistemological transformation and pluralism presents a solution to problems derived from dominant cultural assumptions and practices. My aim for this article is to extend upon the literature pertaining to decolonising methodologies, with this contribution of focusing on the research process as a means to avoid paradox in the decolonial intention. Accordingly, a process imperative that focuses on how researchers do research, over the tendency to focus on outcomes, emerges as a strategy to identify and contend with paradoxes within decolonial work. A questioning convention is posited as a means for mining the assumptions and biases of the dominant culture that would otherwise ensnare ones thinking. Consequently, research may be better liberated from oppressive colonising practices that are tacit within research and academic conventions. Narratives are provided throughout for illustrative example, and to better explore the concepts named.

Collaborative research: Working together to deliver land-based prison initiatives

Collaborative research offers an opportunity to access experiential knowledge, rooted in a process that aims to move beyond traditional research relationships and boundaries. Collaborative research does not always change the power differential; nonetheless, it has the potential to lead to ethical relationships and for partnership working that supports ‘change’. Working in this way aids in understanding and advancing ideas for change, grounded in the views and experiences of all involved. In this article, we share our experiences of carrying out two collaborative land-based prison-based evaluations. These programmes, delivered by third sector organisations, have both worked with men in prison but differed in relation to focus, approach, timescale and the specific group of men targeted within the prison population. This work highlights how working collaboratively lends itself to a way of engaging, through building a range of relationships with key stakeholders, men in prison, prison staff and practitioners, a channel to ‘knowing differently’ and potential for creating humanising spaces within the prison environment. This article details the rewards, tensions and challenges we have encountered when carrying out land-based studies, illuminating additional dimensions for consideration when adopting this approach.

Incarcerated aboriginal women's experiences of accessing healthcare and the limitations of the 'equal treatment' principle

Background

Colonization continues in Australia, sustained through institutional and systemic racism. Targeted discrimination and intergenerational trauma have undermined the health and wellbeing of Australia’s Aboriginal and Torres Strait Islander population, leading to significantly poorer health status, social impoverishment and inequity resulting in the over-representation of Aboriginal people in Australian prisons. Despite adoption of the ‘equal treatment’ principle, on entering prison in Australia entitlements to the national universal healthcare system are revoked and Aboriginal people lose access to health services modelled on Aboriginal concepts of culturally safe healthcare available in the community. Incarcerated Aboriginal women experience poorer health outcomes than incarcerated non-Indigenous women and Aboriginal men, yet little is known about their experiences of accessing healthcare. We report the findings of the largest qualitative study with incarcerated Aboriginal women in New South Wales (NSW) Australia in over 15 years.

Methods

We employed a decolonizing research methodology, ‘community collaborative participatory action research’, involving consultation with Aboriginal communities prior to the study and establishment of a Project Advisory Group (PAG) of community expert Aboriginal women to guide the project. Forty-three semi-structured interviews were conducted in 2013 with Aboriginal women in urban and regional prisons in NSW. We applied a grounded theory approach for the data analysis with guidance from the PAG.

Results

Whilst Aboriginal women reported positive and negative experiences of prison healthcare, the custodial system created numerous barriers to accessing healthcare. Aboriginal women experienced institutional racism and discrimination in the form of not being listened to, stereotyping, and inequitable healthcare compared with non-Indigenous women in prison and the community.

Conclusions

‘Equal treatment’ is an inappropriate strategy for providing equitable healthcare, which is required because incarcerated Aboriginal women experience significantly poorer health. Taking a decolonizing approach, we unpack and demonstrate the systems level changes needed to make health and justice agencies culturally relevant and safe. This requires further acknowledgment of the oppressive transgenerational effects of ongoing colonial policy, a true embracing of diversity of worldviews, and critically the integration of Aboriginal concepts of health at all organizational levels to uphold Aboriginal women’s rights to culturally safe healthcare in prison and the community.

Holistic Conceptualizations of Health by Incarcerated Aboriginal Women in New South Wales, Australia

While there has been extensive research on the health and social and emotional well-being (SEWB) of Aboriginal women in prison, there are few qualitative studies where incarcerated Aboriginal women have been directly asked about their health, SEWB, and health care experiences. Using an Indigenous research methodology and SEWB framework, this article presents the findings of 43 interviews with incarcerated Aboriginal women in New South Wales, Australia. Drawing on the interviews, we found that Aboriginal women have holistic conceptualizations of their health and SEWB that intersect with the SEWB of family and community. Women experience clusters of health problems that intersect with intergenerational trauma, perpetuated and compounded by ongoing colonial trauma including removal of children. Women are pro-active about their health but encounter numerous challenges in accessing appropriate health care. These rarely explored perspectives can inform a reframing of health and social support needs of incarcerated Aboriginal women establishing pathways for healing.

Aboriginal mothers in prison in Australia: a study of social, emotional and physical wellbeing

OBJECTIVE

To describe the social, emotional and physical wellbeing of Aboriginal mothers in prison.

METHODS

Cross-sectional survey, including a Short Form Health Survey (SF-12) and Kessler Psychological Distress Scale (5-item version) administered to Aboriginal women who self-identified as mothers.

RESULTS

Seventy-seven Aboriginal mothers in New South Wales (NSW) and 84 in Western Australia (WA) participated in the study. Eighty-three per cent (n=59) of mothers in NSW were in prison for drug-related offences, 64.8% (n=46) of mothers in WA were in prison for offences committed under the influence of alcohol. Sixty-eight per cent (n=52) of mothers in NSW and 35% (n=28) of mothers in WA reported mental health problems. Physical (PCS) and Mental (MCS) component scores of SF-12 varied for mothers in NSW and WA. Mothers in NSW experienced poorer health and functioning than mothers in WA (NSW: PCS 49.5, MCS 40.6; WA: PCS 54.4, MCS 48.3) and high levels of psychological distress (NSW: 13.1; WA 10.1).

CONCLUSIONS

Aboriginal mothers in prison have significant health needs associated with physical and mental health, and psychological distress. Implications for public health: Adoption of social and emotional wellbeing as an explanatory framework for culturally secure healthcare in prison is essential to improving health outcomes of Aboriginal mothers in prison in Australia.