Dr Kate Davies

Objectives: Bangladesh has achieved notable success in improving maternal health by increasing women¿s access to good quality and low-cost maternal health care (MHC) services. However, the health system of Bangladesh has earned criticism for not ensuring equitable MHC access for all women, particularly for Indigenous women in the Chittagong Hill Tracts (CHT). Little is known about Indigenous communities¿ perspectives on these inequalities in MHC service access in the CHT. Therefore, this study aimed to explore Indigenous communities¿ perspectives on challenges and opportunities for improving MHC service access in the CHT. Design: This qualitative descriptive study was conducted in two sub-districts of Khagrachhari between September 2017 and February 2018. Eight Indigenous key informants from three Indigenous communities (Chakma, Marma and Tripura) were recruited via snowballing and purposive techniques and participated in face-to-face, semi-structured interviews. Key informants comprised community leaders and health care providers. Data were analysed thematically using Nvivo12 software. Results: Findings suggest that distance, poor availability of resources and infrastructure, lack of community engagement in the design of health interventions, Indigenous cultural beliefs, misconceptions about MHC services, and maltreatment from health care providers were the key barriers to accessing MHC services; all are interconnected. Indigenous women faced humiliation and maltreatment from MHC staff. Failure to provide a culturally-safe environment suggests a lack of cultural competency among health staff, including Indigenous staff. Conclusion: Findings suggest that cultural competency training for all health care providers is needed to improve cultural appropriateness and accessibility of services. Refresher training and undisrupted supply of basic MHC services for front-line care providers will benefit the entire community and will likely be cost-effective for the government. Designing health programmes through extensive community consultation is essential.

Objective: This evaluation considered the potential of We-Yarn, a suicide prevention gatekeeper training workshop, to contribute to Aboriginal suicide prevention in rural New South Wales. Design: A mixed methods approach included surveys, in-depth interviews and workshop observations. Setting: Aboriginal suicide prevention training in rural New South Wales, Australia. Participants: Attendees at We-Yarn training. Intervention: We-Yarn provided culturally safe suicide prevention skills training for Aboriginal people and for those who work with Aboriginal communities and persons in rural New South Wales. Training workshops were delivered across multiple locations for 6 hours in one day. Workshops were facilitated by two facilitators with lived and professional experience; one Aboriginal and one non-Aboriginal facilitator. We-Yarn content was developed by staff from the Centre for Rural and Remote Mental Health, and in consultation with Aboriginal Elders and representatives of Aboriginal Medical Services to ensure relevance and cultural appropriateness. Main outcome measures: Pre and post-workshop surveys captured capacity and participants¿ confidence in identifying and responding to a person at risk of suicide. Interviews explored participants' experiences of workshops, implementation of learning, and attitudes regarding social and emotional wellbeing and suicide. Observations detailed the workshop environment, participants' engagement, and participants' responses to facilitators and content. Results: We-Yarn was considered culturally appropriate. Participants responded to facilitators' lived experiences. Participants reported significant improvements in understanding the links between cultural strengths, social and emotional wellbeing and suicide prevention. However, health professionals with existing knowledge wanted a stronger focus on clinical training. Conclusion: We-Yarn promoted discussion of suicide prevention within a holistic health framework, building on participants' pre-existing knowledge about social and emotional wellbeing. Importantly, skilful facilitators with lived experience were vital to the success of the workshops. Consideration should be given to attracting people with low suicide prevention knowledge to the workshops, developing tailored workshops for health professionals and ensuring prolonged engagement with communities. Multifaceted and long term responses in addition to this type of training are important.

Objective: Mental health peer support workers draw on lived experience to provide benefit to people experiencing mental distress. People living in rural areas are less likely than their urban counterparts to seek professional help for psychological distress. The aim of this study was to explore the perceived value of rural peer support workers as facilitators to rural mental health help-seeking. Design: Data were gathered through a cross-sectional survey distributed by a social media boosted post. Setting: A total of 349 ¿small¿ rural towns in New South Wales as defined by the Modified Monash Model classification system as MMM5. Participants: A total of 765 adult, rural residents completed the survey. Main outcome measure(s): Participants were asked to select, from a list of potential facilitators, those which they felt would make mental health help-seeking easier or harder. Results: Study participants felt that a help provider with lived experience of mental illness or distress would make mental health help-seeking easier. Similarly, rural life experience in a help provider was thought to facilitate help-seeking. Participants also believed that flexible and informal meeting settings would make it easier to seek help for mental distress. Conclusions: Engaging rural mental health peer support workers in a flexible/informal setting, as a complement to conventional health service provision, may increase rural help-seeking for mental distress. Increased mental health help-seeking is likely to have a positive impact on instances of serious mental illness.

Objectives: Globally, Indigenous people have lower-health status compared to non-Indigenous people due to unequal access to health care. Barriers or enablers to accessing maternal health services by Indigenous women are not well researched. This review aims to determine accessibility and utilisation of maternal primary healthcare services among Indigenous women in lower- and middle-income countries. Methods: We conducted a systematic integrative review of published and grey literature published between 2000 and 2017. Studies on maternal healthcare service utilisation by Indigenous women in lower- and middle-income countries were included. From 3092 articles identified, 10 met the eligibility criteria. Results: The most prominent barrier to accessing maternal primary healthcare services was the top-down nature of intervention programmes, which made programmes culturally unfriendly for Indigenous women. Distance, cost, transport, accommodation, language barriers and lack of knowledge about existing services also impacted access. Conclusions: Findings provided insights into understanding the gaps in existing policies for Indigenous women and their access to maternal health services. Results suggested that efforts be made to ensure appropriate programmes for Indigenous women¿s maternal health right.

Gray M., Davies K., Butcher L. Finding the right connections: Peer support within a community-based mental health service. This article reports on a qualitative study that examined the organisational enablers and barriers to implementing peer support work in an Australian, rural, community-based mental health service. Interviews with 19 peer and non-peer staff were conducted to identify attitudes towards peer support and whether there were organisational values, practices and strategies that might support the implementation of peer support. The findings revealed that peer support workers were valued for their ability to build trusting connections with clients and to accept client choice in a non-judgemental way. However, peer support workers tended to ¿fill service gaps¿ within intensive, administrative case-management environments. These findings highlight the importance of an organisational-wide approach to integrating peer support, where the responsibilities for adopting new ways of working fall to all staff, not just the peer support workers themselves. Key Practitioner Message: ¿ Practitioners placed high value on the peer support workers on their teams due to their unique personalised engagement with clients; ¿ The roles of peer support workers were poorly understood by team members; ¿ Organisational integration of peer support principles could improve the way all staff engage with clients to reflect a recovery orientation.

This paper draws on findings from an Australian study of mental health service users' perspectives on service user participation to examine the challenges for translating recovery policy into practice. It considers the ways in which national mental health policies and developing welfare reforms reflect and/or contradict the highly personal mode of recovery important to service users; though they seemingly signal potential wins for service user empowerment, they are accompanied by losses for those who do not fit neatly into clinical categorisations. The service users (n = 11) and service providers (n = 6) interviewed for this exploratory qualitative study revealed that recovery was a lifelong process of fluctuating capacity and described a system poorly equipped and often unwilling to move beyond tokenistic modes of participation. The analysis of service user perspectives against the backdrop of policy reform reveals the ongoing tensions between personal and clinical definitions of recovery.