The University of Newcastle, Australia

Circling around the burning issues: a cultural approach to an Indigenous health issue

Michelle Bovill is investigating culturally responsive approaches to empower Aboriginal women to quit smoking during pregnancy.

Not many researchers could claim a one hundred percent agreement rate for their first health care study.

It is an especially extraordinary claim when the people involved belong to a group who can experience unique barriers to accessing quality health care.

Wiradjuri woman, PhD candidate, and Heart Foundation Australia Indigenous Scholarship recipient Michelle Bovill has done just that.

Michelle’s wildly successful study, exploring health care delivery to Aboriginal women during pregnancy in smoking cessation support, has informed the ICAN Quit in Pregnancy intervention program, now underway, with plans for further expansion.

Just don’t credit Michelle with the knowledge uncovered during her work.

“My research is about working with Aboriginal women and capturing their voices in the research space to develop interventions that are empowering and supportive for them,” Michelle says.

“It’s not my research, I’m just writing it.”

“This research belongs to the women sharing their stories.”

The truth about compliance

With extensive experience in youth work, community development, and out-of-home care, Michelle has a practical understanding of the power of support services delivered in a culturally responsive, person-centered manner.

Whilst listening to the stories of Aboriginal women, identifying supports, and attempting to uncover barriers to them accessing or accepting smoking cessation support during pregnancy, Michelle made a startling discovery.

“It turns out that a lot of health providers are telling Aboriginal women to reduce smoking in pregnancy, instead of telling them to quit,” Michelle says.

“And these women are reducing smoking, so they are actually following the advice of their health care providers.”

“The messages in medical services in general is that reducing is a good thing,” Michelle explains.

“With this research we are trying to change that line, we do not talk about reducing at all.”

“Ideally, we want to change this message and ensure every Aboriginal woman is given the means and motivation to choose to cease smoking during pregnancy.”

Barriers and supports

Health care providers themselves offered feedback that telling people what to do may impact negatively on rapport building, or that Aboriginal mums ‘just don’t want to talk about quitting’.

With statistics suggesting a large percentage of Aboriginal health care workers themselves smoke, Michelle suspects avoiding feelings of hypocrisy is also a motivator to not broach the topic.

Michelle collaborated with two Aboriginal Medical services, and her circle of pregnant mother advisors, to develop resources and educational material for both Aboriginal health services and the women being offered support by them.

For the pregnant women, the intervention program is interactive, ongoing, and informative.

For health services, a webinar training approach looks to build skills in workers.

“We want to build capacity of health care providers so they feel confident to say it is best to quit and we can make a plan to support you so you are not alone.”

“It can be a difficult subject to deal with, but in the end, health workers just needs the right training to deliver the right message.”

Reproducing success

Michelle’s research has directly fed into the Indigenous Counselling and Nicotine (ICAN) Quit in Pregnancy program led by UON’s Professor Billie Bonevski and Associate Professor Gillian Gould.

The program is currently being piloted in six Aboriginal Community controlled health services across three states.

It will examine whether culturally-appropriate training helps providers use evidence-based behaviour change techniques to help pregnant women quit, compared to using their standard model of care.

“Within the intervention I am specifically measuring the growth and empowerment of Aboriginal women through their pregnancy, to see if there is any change in growth and empowerment through being offered smoking cessation support,” Michelle says.

“To date, Aboriginal health care research is all deficit focused, when the reality in this case is that they're doing what the doctors are telling them to do, so let’s stop stating the prevalence and collaborate for better support strategies” Michelle says.

“So not only do we need to improve processes to improve outcomes, but we need to correct the narrative as well.”

Thanks to recent funding from the NHMRC, the team will soon roll out the ICAN QUIT program in collaboration with around 30 Aboriginal health care services around the nation.

Building interventions that work

Michelle admits to sometimes being challenged to find what she believes to be the right balance between academic tradition and authenticity in her representation of Aboriginal women’s voices.

Nonetheless, her recent paper “Collective and negotiated design for a clinical trial addressing smoking cessation supports for Aboriginal and Torres Strait Islander mothers in NSW, SA and Qld - developing a pilot study” was accepted for publication by the Australian Journal of Primary Health with minimal edits.

The paper describes the process of developing an intervention collaboratively with Aboriginal and Torres Strait Islander people and communities that evolved from the stories shared by Aboriginal women during her initial study.

Although Michelle’s approach of working with individuals and communities instead of at them seems like common sense in the new age of person centered care, it is a new experience for many participants.

“Some of our communities get a bit shocked,” she notes.

“I have implemented this process where we don't do consultation, we do ongoing conversations, and transparency is everything.”

Michelle believes it is essential for Aboriginal researchers to share information about successfully working in collaboration with Aboriginal people to uphold Aboriginal rights and ethics practice.

“Maintaining a constant back and forth conversation with these mums might be the long way to do it, but it’s the only way that interventions will work.”

“And if we build any intervention with respect, reciprocity, and trust in mind, anyone would be better supported.”

“Particularly anyone in a vulnerable population group who can feel they are not being judged, and that someone is there to genuinely give a damn about them.”