Implementing the Baby One Program: a qualitative evaluation of family-centred child health promotion in remote Australian Aboriginal communities

The setting

Cape York covers an area of 137,000 km², about the landmass of England. The population is approximately 18,000, 60% of whom are Indigenous Australians [10], dispersed across a network of small communities and towns (Fig 1).

Most Aboriginal communities in the region have been, at one time, dispossessed and brutalised by outside colonisation. Today, limited employment opportunities contribute to socioeconomic disadvantage, the primary driver of the high maternal and neonatal morbidity and mortality when compared to the non-Indigenous population [11].

Health services are provided by state government Queensland Health, the Royal Flying Doctor Service, and Apunipima. Apunipima is an Aboriginal community-controlled health organisation that delivers primary health services to 11 Cape York communities. In the region, Cooktown Hospital only accepts low-risk pregnancies whilst the hospital at Weipa provides no peri-partum obstetric services. Thus, at 36 weeks gestation most pregnant Cape York Indigenous women must journey south to Cairns to await childbirth.

Development and implementation of the Baby One Program

In Cape York communities, when a new baby is born, he or she is often referred to as ‘Baby One’. The BOP was introduced on 1 July 2014 designed as a structured, Indigenous Healthworker-led family visiting program that begins at confirmation of pregnancy and continues until ‘Baby One’ reaches 2 years and 10 months of age. Completion of program delivery is deliberately timed for assessment of family engagement with local primary health services; based on whether the family attends the child’s three-year health check.

The program was designed for Indigenous Healthworkers to engage with families and infants across 15 visits throughout pregnancy and the early childhood years. Visits were delivered in a place preferred by the family – usually outside a clinical setting. Timing of the visits was intended to complement an existing clinical schedule, so Healthworkers, midwives and child health nurses could work in partnership. Indigenous Healthworkers engaged with families using a case-load model in collaboration with midwives and child health nurses. There was potential for the Healthworker and family to develop a strong relationship over several years of continuous care.

BOP components included seven baby baskets and relevant health promotion ‘yarning’ (conversation) topics and activities. Basket contents were used to support key child and maternal health promotion messages and included items such as clothing, information sheets, recipe books, personal hygiene items for the mother and a Pēpi-Pod® Program portable sleep space accompanied by safe sleep education. Thirty-seven yarning topics focus on the issues outlined in Fig. 2.

The BOP was implemented using a pragmatic, stepwise approach driven by each community’s primary health service capacity and staffing arrangements. Delivery was initially in four of the 11 Cape York communities and was progressively extended to nine communities by December 2015. Between July 1, 2014 and December 30, 2015, the BOP enrolled 161 pregnant women and their families. There was 100% uptake of the program; all families who were invited to enrol in the BOP model of care agreed to participate.

Choice of study method and ethics

A qualitative approach used semi-structured interviews and a focus group to explore experiences of people involved in implementation and also the participants in the BOP. The James Cook University Human Research Ethics Committee granted ethics approval (H6260). Apunipima commissioned the study through James Cook University. Interview participants gave written informed consent and focus group participants verbal consent.

Data and analysis

In the second phase of data collection, Indigenous Apunipima staff invited family participants to face-to-face interviews (Additional file 3). Ideally, family members would have participated in their home community and been recruited and interviewed in the participant’s first language or language of choice. Necessity driven by scarce resources meant interviews were conducted in English while expectant mothers were in Cairns awaiting childbirth, a potentially stressful period due to dislocation from community and loved ones. Four family members participated (two mothers and a couple). The interviews focused on experiences of parenting; participants were asked about aspects of the program that worked well and those that did not work well, specifically (i) baby baskets and health information; (ii) delivery of the program by Indigenous Healthworkers; (iii) support when women came to Cairns to give birth; and (iv) program engagement with family members. All interviews were arranged at a time convenient to participants late in 2015.

Final data collection came from a focus group attended by 20 men (including two men from families enrolled in the BOP program), led by Apunipima’s Men’s Health Team (Indigenous male Healthworkers) convened in a Cape York community where the BOP was implemented.

Data from interviews with Apunipima staff were coded and compared until recurrent concepts and interrelationships were identified. The process was repeated until higher order constructs and relationships could be modelled to explain the data, forming a theoretical model of BOP implementation. The theoretical model was presented to staff and the Research Governance Committee at Apunipima. However, presentation of the data in a theoretical model was not supported as being an accurate reflection of their experience. Strong views were expressed that while the model may have been consistent with early development of the program, it was no longer relevant or applicable to current practice. The research data was pertinent to time from the outset of BOP implementation, however, the program transformed across 18 months of development. In this instance, subjectivity inherent in grounded theory constructivism and theoretical re-formulation of the data [14] was possibly at odds with positivist views which may have relied more on current observable facts. There was an intention to engage staff, particularly Indigenous Healthworkers, in data analysis to add important contextual insights. Contractual project timeframes combined with Apunipima staff clinical workloads involving frequent travel to remote communities precluded this process. The grounded theory approach did not clearly set out future implications of the research findings for Apunipima staff.

Qualitative researchers must select from an array of representational styles, those that best fit their research purpose, methods and data [15]. The grounded theory theoretical model was abandoned and data from the three participant sources (family participants, Apunipima staff and men’s focus group) were imported into NVivo. A thematic analysis was undertaken to generate initial codes, search for themes among codes and define and name themes. The key study themes are presented with quotes to share the voices of participants and provide illustration of the findings.

Senior Apunipima researchers and the BOP team subsequently came together in a collaborative workshop to develop a strategy for strengthening processes and ongoing evaluation of the BOP. It was important that recommendations could potentially be adopted within day-to-day program delivery context. A series of brainstorming, sorting and prioritising activities using the themes identified in the study data derived a set of practical recommendations that are presented in the Discussion.

The central concern and process

From the data, the key to effective program implementation was the relationships formed between health practitioners and families. Program development and quality improvement was contingent on responsiveness to family needs. Staff members identified the need for respect, empathy and positive language: “…they [families] know that they have a safe place to talk, because I build that relationship” (IHW). Mothers are essential partners in the BOP, but a relationship with the whole family was viewed as important. “The way that it should be done is about building relationships with those families and maintaining them over the 1000 days” (R-S). Some believed program implementation could be more responsive by valuing and validating decision-making capacities of family members. “It should be more family led…” (R-S). An Indigenous Healthworker believed the program was achieving this. “It just lays it all out well for them to be able to take control of their health and their baby’s [health]…it is important for [families] to have…control over their own health.”

In the process of evaluating context in the implementation of the BOP two key factors were identified from the data: challenging environments for new families and valuing cultural ways.

Challenging environments for new families

The conventional view, that people in Cape York Aboriginal communities have close family and kinship ties, implies that the responsibility of caring for children is shared between parents, grandparents, uncles and aunties. However, two of the three mothers interviewed stated that they did not always have family support in caring for their infants. One said: “You don’t get any other support from your families.” The other commented “Well, I don’t have much family. That’s why I’m making family.”

Family members believed that the mother’s evacuation to Cairns at 36 weeks, without her immediate family, assumes that her other children will be cared for by her partner and/or extended family members. Men noted that exclusion of the father at the birth of his child could establish a pattern of the absent father; they advocated: “Involvement from the start [will create] acknowledgement of family members…If [fathers are] involved, support will continue. Involve the man more.” (Men at focus group). An Indigenous Healthworker agreed “…the father’s got to be a part of that thing from day one…it’s like you want to be with your wife, your newborn, you’ve got to be a part of this child from the beginning”.

Another Healthworker said “you can see that families really need it, especially first time mums.”

Valuing cultural ways

An Indigenous staff member reflected, “I think part of building healthy children is strengthening culture. It’s also a reflection time for the mother too, she is reflecting on her culture too, she is passing it on to baby.” (P-S).

An Indigenous Healthworker confirmed the importance of a family-centred approach in the BOP. She said the program, “educates the whole family, so it’s in the household and you are giving the information to the mother and her brothers and sisters or her aunty or grandma or who will be there looking after that baby.” She continued, “it’s really good because you use your normal body language and eye language and you can do it in a more culturally appropriate way for your community.”

Three key enablers of BOP implementation were identified from the data: resourcing program delivery, working towards a team approach and negotiating the cultural interface.

Resourcing program delivery

The BOP is funded by the Commonwealth and Queensland governments. The initiative is regarded as a flagship program of Apunipima, however resource limitations across the organisation have meant amendments to program support, including plans for expanded employment. Full implementation of the program across all 11 Apunipima communities remained to be achieved at the time of data collection.

Staff workloads are often high and there are substantial service delivery expectations. Healthworkers are responsible for clinical service in addition to health promotion work,“…it’s a really great concept, but in other ways there’s a lot of pressure on people to do it now and have results now…” (R-S). The time commitment for Healthworkers was particularly high during the first year of the program because families are enrolled at their first antenatal visit and early scheduled visits are close together. The projected ideal caseload is 25 families but one Indigenous Healthworker reflected, “In [community name] about 16 or 17 and that is ante and post-natal, and in Cairns there is about 12 on the list.” A community-based Indigenous Healthworker said “…we definitely need more Healthworkers on the ground”.

The program included one full-time position to provide ‘on-the-ground’ training and support to BOP Healthworkers across nine communities. Field support was regarded as an important adjunct to formal BOP Healthworker training. Managers and Healthworkers urged the need for allocation of more resources to heathworker support, however, the high cost of bringing staff together over long distances for formal training blocks resulted in a reduction from quarterly to bi-annual face-to-face training workshops.

Working towards a team approach

The BOP arose from Apunipima’s strategic decision to realign maternal and child health into a family-centred, Healthworker-led service.

There was divided opinion about involvement of Healthworkers in development of the program. Whilst one staff member believed that the BOP manual was “…literally dumped…on the Healthworkers, implement it, and own it” (P-S), an Indigenous Healthworker said “from the time that I first started, Healthworkers have a real good influence on how the [program] is delivered and how the education…is given to communities.”

The focus on Healthworker leadership meant that some nurses and midwives felt excluded. A health practitioner said it seemed like, “they didn't want the RNs [Registered Nurses] involved.” (R-S). An Indigenous Healthworker said there was a “big divide between a Healthworker and nurses…even though we don’t have a university degree, we have all this other knowledge that probably can’t be written on paper.”

A manager acknowledged early confusion over professional roles and reported the steps made to address the concern. “When a new Healthworker comes on, the midwife is part of that learning journey, so even though it’s…being led by the Healthworker through the cultural expertise, and the midwife as the expert in the clinical…we are walking together.” (P-S).

Some identified the future challenges of the program and delivery of its full potential. “I think because the program is in its infancy. There is a lot of room for improvement and there are areas that need to be worked on to ensure that.” (IHW).

Negotiating the cultural interface

Apunipima values a strong Indigenous workforce as the way to build culturally-safe relationships with community members and connect them to health care resources.

However, because Indigenous Healthworkers live in the community and are often family members, they may face cultural barriers when working across gender, or kinship relationships. “…when it is a community person, sometimes they might not be able to speak to or have a lot to do with one side of community” and“…you'll find that sometimes in the communities, the female Healthworker may not be allowed culturally to speak to that male or father.” (P-S). To address these cultural needs, roles are negotiated across program staff members.

Three key strategies of BOP implementation were identified from the data: engaging families, exchanging knowledge through yarning and strengthening the workforce.

Engaging families

Initial engagement through the BOP provided a foundation for effective ongoing relationships. A health practitioner explained, “…to me the engagement part is the most important part. You get that right, everything else is just going to come in” (R-S) and “[as] a first time mum…you need to build a relationship with the team that is going to be there for you right through…your pregnancy and then through the upbringing of your child.” (P-S).

Communication style was cited as important. “…we use broken English to explain things. I find the BOP gives you more options to talk about what is actually going on with people’s lives, not only the child, but the mum and the dad.” (IHW). Baby baskets delivered by Healthworkers during family visits are used to engage with families. Most expressed appreciation for the baskets, and found the contents helpful. One mother said, “The baskets are good, it’s helpful, and I’ve never had anything like that before...” Another mother said that she did not previously have what she needed for the baby, “I didn’t have enough chance to get much for the baby when I was down in Cairns [for birth]. It was too much…I couldn’t leave my one year old…”

It is convenient for some families to be visited at home, especially parents with small children. One mother said, “Yes, [home visiting] it’s helpful, it saves me going all the way up [to the clinic]...because sometimes I don’t have the time to go.” Other families prefer to meet the Healthworker outside their house. One Indigenous Healthworker explained, “We can have it [home visit] outside on the veranda. I wait for them to tell me where they want it to happen…”. When families “are more comfortable, they are more likely to open up to you. I find with the BOP that people are inviting us in.” (IHW).

Exchanging knowledge through ‘yarning’ (conversation)

Family members noted that knowledge exchange through the program was helpful. One mother agreed that she was able to talk about issues that concerned her and understood the response provided. Indigenous Healthworkers reported that yarning about health and wellbeing topics is best done in the context of a relationship. The preference for having the same Healthworker through a woman’s pregnancy and post-natal period was noted by one mother, “Yes, I rather stick to one.”

The BOP manual summarises the content of yarning topics in order to support consistent delivery across Cape York communities. Some Healthworkers discuss the topics in a prescribed order, while others use them according to the needs of the family. Some were reluctant to talk about sensitive topics such as family violence or sexually transmitted infections. “The workers based in the community, they…were just like no, I don’t feel comfortable with talking about this” (R-S). However, a senior Indigenous Healthworker, when asked if there were any health promotion topics she felt she couldn’t raise with families, said “No, I’m quite confident”.

Sensitive yarning topics were developed and presented via educational videos. A Healthworker said, “I use the iPad if the lady is real quiet and doesn't talk much…so I just use the visual so she doesn't have to say anything.” Another staff member said, “…it [the video] took the pressure off raising and having those conversations…even to raise that topic.” (P-S).

One Indigenous Healthworker believed that the yarning topics made a positive difference. She reported that a mother “said ‘you know I’ve never really had education like this before’” and “…some of the ladies that we do education around, they kind of nod their head and say ‘oh we didn’t know that’.”

Strengthening the workforce

Apunipima’s strategies to strengthen program workforce included training and supporting Healthworkers with a commitment to recruiting new positions from Cape York communities. A health practitioner observed, “…the capacity of Healthworkers is different, so some will need more support and maybe just reminding.” (P-S). Continuing investment in Healthworker support and training has been regarded as critical to the ongoing successful delivery of the program.

There was also an opportunity to promote coordination between the BOP Healthworkers and the Apunipima Men’s Health Team. An Indigenous Healthworker said, “I just believe you need to work together for this to succeed.” A health practitioner agreed “…it would be a really good program where male Healthworkers were working with the fathers through pregnancy, for a thousand days [and] could become very much involved.” (P-S).

Early formative outcomes identified from the data of BOP implementation were related to seeing health changes in families.

Seeing health changes in families

The program promoted good health through behaviours such as quitting smoking and reducing consumption of alcohol. “People will come up to me in community and say that they (don't) smoke any more, or I’ll hear good feedback from other family members” (IHW). A mother reported her achievement in giving up smoking and drinking, “…both of us used to be bad at smoking and drinking…but we just gave it up.”

Family members also reported feeling more comfortable at their local clinic, visiting the clinic more often and better engagement with clinic staff. A mother noted that she saw the Healthworker “a lot more” than for her previous children, and that she liked the Healthworker visits and involvement of the midwives.