The data revealed the following key themes: challenging environments for new families and valuing cultural ways, resourcing program delivery, working towards a team approach, negotiating the cultural interface, engaging families, exchanging knowledge through ‘yarning’ (conversation), strengthening the workforce, and seeing health changes in families. Data from Apunipima staff interviews were coded to clearly distinguish between staff involved in program delivery, who were all Indigenous Healthworkers (IHW), and those who provided related services (R-S); as doctors, midwives and maternal and child health nurses, allied health staff and health promotion officers; or program support (P-S) via management and administrative roles.
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”.
Household overcrowding challenges some families. Mothers reported that living situations can be distressing.
“I’m tired because we are in the middle of everything, and it’s really noisy, and there’s just parties here, parties there, and it’s like really loud and straight through us. I don’t know how [baby] coped with it all” and, “…it’s hard, it’s pretty noisy, but you’ve got to cope with it.”
A need to provide support for new mothers is clearly recognised by Indigenous Healthworkers.
“Everything can be a bit too much … you’ve been out of community [in Cairns] for 4-6 weeks, depending on whether you gave birth on your due date…the stresses of being a new mum again.” (IHW).
Another Healthworker said “you can see that families really need it, especially first time mums.”
Valuing cultural ways
Because many traditional roles of men (as hunters and providers) have changed, fathers are often expected to take on roles and tasks within the family that were once the domain of women. One health practitioner observed:
“I think it’s shared roles…nutrition is not all mums’ business. And the stuff around the bathing. This is where we challenge fellas. It might be taboo for you to bath babies, but it’s not taboo for you to get the bath ready…A lot of fathers want to be involved, but they just don’t know how.” (R-S).
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 quality improvement approach and new ideas resulted in evolution of the program’s structure and content. Indigenous Healthworkers and midwives reported that their work roles became more clearly defined. A health practitioner commented:
“We know that it is Healthworker-led…If the Healthworker is struggling and wants assistance, then yeah, they can ask and we can do that…” (R-S).
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).
BOP implementation has provided an opportunity for knowledge exchange between Indigenous Healthworkers and other health practitioners. A comment by one Apunipima staff member exemplified openness to hearing new ideas,
“It is an opportunity for us to learn from each other without having to reinvent the wheel…someone within the group may have a suggestion that might knock our socks off and make a real improvement to how we do things.” (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.
Ideally, Indigenous Healthworkers can translate and explain Western medical concepts in language more easily understood by family members.
“If you're going in to a…clinic and you feel scared because your child is sick…people use big words that you're not used to... And if you have the Healthworker that you actually really trust, has been seeing you in your home, knows you, has been knowing you for about a year, and you can look to her and you can say ‘what are they talking about?’” (P-S).
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.
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.”
Healthworkers reported a reduced risk of families engaging with the Department of Child Safety because of the support provided by the BOP.
“With help of the Baby One Program and the support network of the midwives and the Healthworkers, we’ve actually stopped a lot of that happening. Because we say to Child Safety, ‘oh no, they’re engaged in this parenting program, this is a parenting visiting program, this is what we do every fortnight.’ I tell them ‘we'll come and see this girl.’ So there’s been lots of good outcomes like that.” (IHW).
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.
A program support staff member concluded that,
“There is the capability of this program to be a source of pride for Cape York Healthworkers and Apunipima, and that relates to obviously their having a positive impact on the families that they’re supporting and delivering health care to…and that’s the bottom line.” (P-S).