Depicted in Figure 2 are the interrelated common purpose and process by which Baby Basket implementation occurred (inner circle), social environment which influenced Baby Basket implementation (outer circle), strategies that combined to comprise implementation (intermediate ring) and consequences of program implementation (lower centre). The model and verifying grounded qualitative data are presented below. Theoretical terms are italicised.
Program implementation entailed empowering families through a process of engaging and relating Murri way between women, family members and healthcare workers. Key influencing conditions of the social environment were the remoteness of communities, keeping up with demand, families’ knowledge, skills and roles and organisational service approaches and capacities. Engaging and relating Murri way occurred through four strategies: connecting through practical support, creating a culturally safe practice, becoming informed and informing others, and linking at the clinic. These strategies resulted in women and families taking responsibility for health through making healthy choices, becoming empowered health consumers and advocating for community changes.
Common purpose: empowering families
The common purpose for those who were active in delivering and receiving the Baby Basket program was empowering families. Empowerment was important for families to ensure that the women and their partners were confident and well prepared for the birth and parenthood so that babies had the best start in life. This was identified in the narrative of one woman who recalled: “I sat down with my partner and he was reading it (Bunjalbi Book included in the antenatal basket) and he’s like, ahhh. He’s a first time father as well you know”. A non-Aboriginal manager also reflected: “If you have a disempowered, sad woman, she is not going to be able to make any of those behavioural changes”. Empowering families was important not only because the Baby Basket aimed to better prepare women for their prospective roles as mothers, but also because extended family members were closely involved in caring for and supporting women and their new babies.
Central process of implementation: engaging and relating murri way
The process of program implementation occurred through engaging and relating Murri way. The baskets provided an initial tool for engagement between women and their family members with Apunipima and other healthcare workers; and this set the foundation for relating Murri way. This referred to the local Murri (Indigenous Queenslanders) way of relating about health issues which involved “yarning” (an Aboriginal concept for coming together informally to share experiences and knowledges) in a holistic way about a woman’s or family’s wellbeing.
A healthcare worker spoke about the baskets as a “tool for engagement”; while another said “it’s almost like your ticket in”. Similarly, the women spoke of their engagement with healthcare workers as: “local faces at the clinic”; and “she [nurse] gave me the basket… she told me about the basket, she introduced me to the girls who were working for Apunipima”. Such perceptions of engagement contrasted with women’s narrations of the non-engagement experienced when they arrived at the regional hospital. For example, one woman said: “that cranky old lady that … don’t even talk to you; you just feel very uncomfortable”. The women appreciated the baskets’ contents and this appreciation established the basis for building relationships with healthcare workers.
Relating Murri way was critical to facilitating the provision of health care. One woman described her appreciation of the basket and the importance of relationships with healthcare workers in preparing women for birth and motherhood:
“the Baby Basket is beautiful to have, especially for women like us Cape York girls, like Indigenous women…its good because more of young girls are getting pregnant …. It’s sort of like a push; a sort of kick on the butt. It’s a good start for them you know.”
In the absence of relating Murri way, the women were sometimes reluctant to seek healthcare advice or assistance. An Indigenous (Murri) health worker reflected that many women would not disclose vital health information to healthcare workers with whom they had no relationship. For example, she recalled:
“On many occasions I’ve taken ladies with mastitis and urine infections. And they would have seen the EMS [Emergency Medical Services] lady that day. But I get the phone call and I take them… so it’s not that the EMS haven’t done their job. They (the women) just haven’t told them”.
An Indigenous health worker also spoke of the importance of relating Murri way with families, suggesting:
“It doesn't really matter who is in the household… because the older siblings will be looking after the kid, or the grannie, or the granddad. So when you do the education, regardless if mum not there, if she is at work or at the shops or something, it’s whoever’s looking after the kid as well who gets that education”.
For healthcare workers, relating Murri way involved a lengthy process of establishing trust and rapport with the women and their family members. For example, an Indigenous health worker said: “For me to relate to the people, I have to get to know them first. If I just chuck myself at them, they won’t bite it”. Thus, the engagement facilitated by the Baby Baskets led to the development and/or strengthening of relationships which provided a foundation for sustained health care through the processes of pregnancy, birth and early parenting.
Engaging and relating Murri way also occurred to some extent between the different professional groups within Apunipima’s transdisciplinary health team (doctors, nurses, midwives and Indigenous health workers); and between Apunipima and partner organisations. A non-Indigenous health manager spoke about the benefits of inter-cultural relating between Indigenous and non-Indigenous health professionals:
“The [Indigenous] health worker is learning at the same time, and the nurse is also learning what the best way is to approach a family and what the wording has to be, what the languaging is around things, what the traditional words are for Indigenous language and are appropriate for use in certain circumstances. So you know there is a lot that can happen in that fairly simple interaction”.
Such efforts towards culturally appropriate engaging and relating allowed healthcare workers to offer more comprehensive care by complementing each other’s skills and experience.
For women, engaging and relating Murri way also occurred with their partners, family and community members, and other women. For example, one pregnant woman provided support to another, recalling of the other woman: “she was getting scared…. And so I go ‘look we go in here, they have got the Apunipima staff here too. You sit down with them and they tell you stories about how big it is, and it’s not scary’” Through engaging and relating Murri way with each other, pregnant women assisted each other with taking on information about pregnancy, accessing healthy foods, linking with the clinic and other health enhancing behaviours.
Conditions of the social environment
Although every Cape York community is different, four key aspects of the social environment affected program implementation. First was the remoteness of communities. Remoteness influenced program provision because of the lack of routinely available pregnancy and baby goods in remote communities. Remoteness also affected families’ ability to make healthy choices because many remote communities lack supplies of affordable fruit and vegetables; what is available is often of poor quality and not affordable. One woman recipient of a Baby Basket commented: “…they will have problems down the track like diabetes, and all these other disease coming along in their pregnancy due to lack of supplying fresh fruit and vegies.” Remoteness also required the universal planned departures of pregnant women from communities at 36 weeks pregnancy to give birth in Cairns. Departures resulted in their separation from family and community support at this critical time, and necessitated additional support from health services.
The second aspect affecting program implementation was keeping up with demand due to the high birth rate, prevalence of risky pregnancies and preventable childhood diseases within these communities. One woman recalled:
“Me and my friend didn’t know we were pregnant, well this girl up here is 3 weeks in front of me. All of a sudden, we went to the clinic. One found out she was 6 weeks - another 2, and 3 weeks later I found out I was 8 weeks pregnant…. next minute, you see all these little tribe running around”.
The high birth rate in remote communities created a strong demand for Baby Basket; particularly in large communities where healthcare workers were stretched to keep up. A health worker narrated her experience of delivering the program in a large Cape York community:
“Did I do the Baby Basket then, oh no, did I do this other one? Shit. There’s other kids - did we get them for their immunisations and child health checks? You know what I mean? It’s mind boggling the amount of women that are pregnant and the amount of kids that are tiny”.
Further, the health issues mentioned by women and healthcare workers included high blood pressure, an ear infection, multiple miscarriages, rheumatic heart disease and gestational diabetes during pregnancies; as well as haemorrhages, and mastitis post-birth. Hence, while the approach of Apunipima was to focus primarily on the women’s and baby’s wellbeing and the family as a whole, many women had risky pregnancies that required medical intervention.
High rates of chronic and infectious diseases also posed challenges for healthcare provision. The common health issues affecting young children were described by an Indigenous health worker:
“…ear health, skin, so scabies, impetigo, are mainly my ones. I don’t know about any other communities but we do, I mean we gave four bicillins in one day to children, like it was that bad. Head lice, eye…”.
The prevalence of preventable diseases reinforced the need for the Baby Basket program; particularly the health education to women and their families.
Third was families’ knowledge, skills and roles in the community, and specifically extant family and/or work responsibilities. For example, one woman reflected:
“I got my own place; I look after my little brother and sister too … My mum passed away when my little one was 9 months…. No one else is going to look after them, so it’s like, I don’t want to see my little brother and sister going to people that won’t help them.”
Such relationships and responsibilities influenced women’s and families’ needs, capacity and choices with regard to their engagement with the program.
Fourth were organisational and service approaches and capacities. The family-centred and community–controlled approach of Apunipima was appreciated by the women. One said:
“It’s really sad when culture dies. Our main person is sick now, old fella, Elder is sick…. that’s why we are trying to get to our youngsters. That’s why it’s really, really good that our partnership with Apunipima and other you know… is Indigenous based”.
Healthcare workers also recognised the influence of Apunipima’s organisational values and processes on work practices. One nurse acknowledged:
“I’m sitting feeling very new to this organisation [Apunipima] having worked somewhere else. The way the whole Baby Basket concept was explained is completely different to everyone’s understanding here. I mean, it’s just different … you’re working in a different capacity…”
Delivery through the “different” community-controlled health-worker-led, family-oriented and home visiting approach enabled clinic staff to build good rapport with women and family members and facilitated implementation that was responsive to community needs and feedback.
Strategies
Engaging and relating Murri way occurred through four strategies which are presented sequentially, but in practice they overlapped. They were: connecting through practical support, creating a culturally safe practice, becoming informed and informing others, and linking at the clinic.
Connecting through practical support
Connecting through practical support refers to the initial engagement between women and healthcare workers facilitated by the provision of the pregnancy, birth and baby goods. Women and healthcare workers considered the items provided through the Baby Basket program to be useful, and appreciated their contribution to preparing women for their changing roles and responsibilities in their families. One woman said:
“…they come in handy. The first one is really good, they provide for mothers, all this stuff you need … the second one … they meant to give us before we go in, it’s got all the baby singlet, clothes, basket, shampoo, singlet, their own towel. I felt over the moon. I thought that’s really good”.
Women suggested that the Baby Baskets were particularly useful for supporting those who were likely to be less well prepared for birth and motherhood – for example, those who were having their first baby, were young and/or required emergency evacuations from communities. Another woman commented:
“… their first baby, they don’t have anyone to support them, you know, it’s really good. It comes in handy…It’s sort of like a showing of the idea of what baby needs, and for themselves, before baby born and after he or she born, you know.”
Although the composition of baskets had been relatively stable since 2009, the women recipients were aware of the small amendments over time. Women also suggested further improvements to the contents of the baskets; primarily additional or amended material items and educational resources. The awareness of amendments and consideration given to recommended changes suggested the high value placed by women on the baskets.
Creating a culturally safe practice
Indigenous health workers engaged with the women and families by creating a culturally safe practice. They did so by engaging and relating Murri way responsively and in a respectful and inclusive manner displaying patience, flexibility, confidentiality and communication skills. Indigenous health workers generally work in their community of origin; hence they have an intimate knowledge of the local social and cultural dynamics. An Indigenous health worker described the flexibility required in responsively relating with women in ways that were culturally safe. She commented: “They’re young and you just having to listen to what people complain about. It may not even be relevant to your job but you’re there, you’re listening.” Another health worker explained that language was critical to families’ interpretation and understanding of health messages: “Yeah we usually speak more Kriol to them and they understand it much better”. The importance of language was also illustrated by use of plain English and use of appropriate visual images in the educational resources (such as the Bunjalbi Book) provided to families.
Non-Indigenous healthcare workers also recognised the critical importance of Indigenous health workers in creating and maintaining that space and ensuring that the women understood the health education and care provided. A midwife talked about the ways she worked with an Indigenous health worker to better understand the women’s needs and ensure better care:
“Often when we sit there and explain things, the ladies will sit there and go ‘yes, yes, yes.’ it’s only when [names of two Indigenous health workers] have gone out after me and they’ll come back and say ‘actually when you said that … they didn’t quite get that’.…You know, and that’s where we learn so much”.
Home visiting was a key strategy for creating a culturally safe practice. This strategy was endorsed by both healthcare workers and women so long as it accorded with women’s preferences. The women experienced home visiting as useful for relieving the stress of having to obtain transport to get to the clinic. An Indigenous health worker considered that home visiting allowed more personal care and enhanced trust: “to me it is like you care, from being in an Aboriginal community, it’s like you come out of your comfort zone and you actually are in their environment and you see what they are going through”. A midwife noted: “the quality of the information you get about a family and how that family operates is just like the difference between a couple of words of description and a picture. It’s hugely different.” However, the logistics of providing three baskets posed challenges in relation to: “too much stuff to carry” outside the clinic; and many healthcare workers commented on the need for access to a dedicated vehicle. The home visiting approach needed to be administered flexibly to account for the varied preferences of women and families and varied cultural customs, and required resourcing.
Creating a culturally safe practice meant that care extended to women’s and families’ social and emotional wellbeing. An Indigenous health worker observed: “They’re too shamed to talk about their social emotional sides, whereas with us they are so connected to us, because they know us”. Engaging and relating Murri way through creating a culturally safe practice enabled discussions about sensitive issues such as cigarette smoking, marijuana use, alcohol and other health and wellbeing issues. For example, in relation to foetal alcohol syndrome (FAS), one Indigenous health worker said that she:
“…felt a bit uncomfortable with talking about the FAS, and they didn’t know anything about it. And some of them go really quiet because they may have drunk early. And I feel like it might be too late to be talking about that. But it is good. Then they’ll know for next time.”
Being assured that confidentiality would be maintained was critical. An Indigenous health worker commented: “I always tell them I can lose my job if start talking to youse about family after hours. So I reinsure that everything is kept confidential”. Thus, the knowledge, qualities and skills of Indigenous health workers, and flexible home visiting approaches allowed healthcare workers to create a culturally safe practice, thereby enabling discussions about sensitive, but necessary, discussions about issues that affected the health and wellbeing of the women and their babies.
Becoming informed and informing others
Within the space nurtured by employing culturally safe practice, women, partners and their families became informed and informed others about prevention and care; this was the third sub-process of engaging and relating Murri way. Women, partners and their families learnt what to expect through the processes of pregnancy, birth and motherhood, how to prevent ill-health, care for themselves and their children, and passed on their learnings to other pregnant women. A health manager commented on the value of engaging partners and other family members:
“…five pairs of ears listening rather than one; including the one who does the cooking and the one who decides who is going to sleep where. And all those things that are really important regarding early life experiences.”
Several women said that they did not know much about pregnancy, birth or child rearing before becoming pregnant. One said: “I wish I’d had done this before. When my first baby. At least I would have known.” Another said: “my mum never talked to me about stuff like this. You know even teenager or growing up”. And yet another woman recalled:
“when we found out we were pregnant, we got our Baby Baskets, and the midwife and you know, Apunipima will tell us um, about the fruit and vegie…. and knowing the safety of the baby, and yourself, and not hurting yourself.”
Once informed, women were keen to share their knowledge to support other family and community members. An Indigenous health worker observed: “they’ll tell others… they’ll pass the word around”.
All healthcare workers said they provided education about safe sleeping for mum and baby; healthy food and nutrition; breastfeeding; general hygiene; smoking, alcohol and other drugs during pregnancy; and wellbeing. However, the entrenched nature of some health issues meant that even though education was regularly provided, healthcare workers remained concerned about its effectiveness in shifting behaviours. For example, a midwife said: “certainly we are giving out those messages about scabies and hearing health and all the rest of it every time… [but]… it’s long term and these issues have been around for a long time.” She continued: “And whether they take it on board is totally different”. Further, they expressed concern that the health promotion messages provided were at the discretion of individual healthcare workers and there was no consistency across the program. Hence, for example, a midwife commented:
“If you’re someone who’s a newish nurse to child health and you’ve never had children yourself and you’re sitting there thinking: ‘Oh God, I’m really not too sure what a six month old eats, but I’m hoping I’m giving the right advice… We can’t be sure; especially if … there is nothing to say that it is okay.”
In order to provide effective prevention and care messages, Indigenous health workers, nurses and midwives practiced two-way learning across roles. A health manager reflected: “the health worker is learning at the same time, and the nurse is also learning what the best way is to approach a family”. However, the concern about whether consistent health messages were provided suggested the need for a revised approach including training to inform healthcare workers about the focus and approach to becoming informed and informing others.
Linking at the clinic
The fourth sub-process, termed linking at the clinic, referred to strategies to encourage women, their partners and children to access the primary healthcare clinic for health screening, checks and treatment and care through continuing the process of engaging and relating Murri way. One of the core aims of the Baby Basket program was to encourage women to attend the clinic earlier for antenatal care. But with young or first mothers in particular, there were barriers to clinic attendance which required careful management through Indigenous health workers’ home visits and community knowledge. An Indigenous health worker reflected:
“We don’t normally catch them very early. Like we’ve got two ladies that are young; like one is probably 17 or two of them are 17, and their bellies are out. So we hear from family that they are pregnant but they never come to the clinic yet. So I don’t know how long they want to hide it for”.
One healthcare worker mentioned that some women were happy to visit the clinic because of the rapport staff built with the women and family members. The employment of Indigenous staff at the clinic was important, with one Indigenous health worker noting: “Some women are in shame for baby, and they go to clinic for check; black nurse they’re alright”. This quote refers to the shame or embarrassment felt by insecure young or new mothers resulting from internalisation of the historical disempowerment of Indigenous Australians; and their perception that other Aboriginal healthcare workers would understand their parenting concerns. However, clinics were not always an appropriate environment in which to provide Baby Baskets. A midwife said:
“you’ve done all this stuff and it’s like ‘oh baby basket’. It’s like an afterthought… Because it was being done in a very busy clinic, where you were very aware who was waiting outside and all the other demands that were upon you”.
Thus, the role of clinics was critical for provision of care, but not a preferred option for handing out the baskets or associated education.
Postnatal visits were important for checking for and treating the diseases experienced by Cape York children and caring for women’s postnatal health. For example, an Indigenous health worker spoke of: “…a boy who is probably eight months, not even that. He was rid with scabies”. Another described an after-hours conversation with a client:
“I had a lady pull me up in the shopping centre and she said ‘Oh, sis, bubby’s not attaching properly, like it’s sore, it hurts when he gets on my susu… I’ve been sick and tired and sleeping all day’ and I said: ‘now darling you really need to go to the hospital. Like now! …It sounds like you got mastitis…’.”
This conversation exemplifies the importance of multiple strategies to enable linking at the clinic through the foundational relationships between healthcare workers and women in facilitating healthcare provision.
Consequences: taking responsibility for health
Baby Basket implementation supported women, family members and healthcare workers in taking responsibility for health. While acknowledging that it was the women’s right to take education messages on board and to change behaviour, health care workers were heartened by examples of women and families making healthy choices. One woman talked about how pregnancy prompted her choice to stop smoking:
“At first I was a really heavy smoker. Like two packets a day… Yeah and when I found out I was probably only three weeks pregnant. And so I gave up straight away. I gave up for two years before I started back up again…Yeah I was really surprised myself”.
Another woman reflected: “I ate heaps of vegies! I would only eat it if it was steamed”. Such examples of behaviour change were heartening.
Women also experienced becoming empowered as health consumers, taking control of their pregnancy, birthing and mothering journeys with the support of the Baby Basket program: “Just learning what happens when your baby comes, or what to expect in labour.” Another woman recalled: “I didn’t want to go through with the pregnancy there…the hospital wasn’t very clean, so I decided to come back home.” Being prepared for the births of their babies’ relieved stress and shame for women, and provided a better start for newborns.
Taking responsibility for health was also observed in women advocating for community changes to improve the wellbeing of other women. One woman worked as a youth worker, and mentioned the important role of providing contraceptive advice and condoms to young people who wished to prevent pregnancy. Two women commented about the availability of quality and affordability of fruit and vegetables in the stores in remote communities; one saying:
“Whenever I go in the shop, I fight for the health of young women, pregnant women, you know, women that are old. I say, ‘why do you put out rotten fruit on the shelf… We get young women who are having babies, and they need fresh fruit and vegies’”.
Two women mentioned that they wished that the baskets could be more widely available so that others could also enjoy their contents. One said: “every mum should be able to get it”. This appreciation by recipients, as well as the willingness and capacity of health providers to deliver Baby Baskets suggests the feasibility of transferring the approach to other sites.
Limitations
A limitation of this study arose from the challenges faced in accessing women who had received the Baby Baskets and who were willing to be interviewed. The women interviewed in Cairns were at least 36 weeks pregnant, were displaced from their normal family and home support structures, and were likely to have had other priorities in preparing for the forthcoming births of their babies. Hence, repeated attempts and arrangements to interview some women were fruitless. Nevertheless, one of the strengths with grounded theory methods is that it allows for the concurrent collection, analysis and development of theoretical codes and categories – this prevents the collection of unnecessary data once saturation is reached.