human resource management 6152

‘What You Do is Important But How You Do it is More Important' Engaging Indigenous Men in Rural Mental Health Services Research

Anton Neville Isaacs MONASH UNIVERSITY

Hugh Pepper

Priscilla Pyett UNIVERSITY OF MELBOURNE

Hilton A. Gruis MONASH UNIVERSITY

Peter Waples-Crowe VICTORIAN ABORIGINAL COMMUNITY CONTROLLED HEALTH ORGANISATION

Mark A. Oakley-Browne TASMANIAN GOVERNMENT DEPARTMENT OF HEALTH AND HUMAN SERVICES

ABSTRACT

Evidence on the methods followed by non-Indigenous researchers for conducting research that in- volves Indigenous people in Australia is sparse. This paper describes the methodology and steps followed by a non-Indigenous researcher for engaging with men from an Aboriginal community in rural Victoria in conducting mental health services research. It describes the process adopted to ini- tiate research and build research capacity within an Indigenous community where Indigenous re- searchers were unavailable and the local communities were ill-equipped to conduct research themselves. The methodology followed was informed by the values and ethics guidelines of the Australian National Health and Medical Research Council, the decolonising methodology of Linda Tuhiwai Smith as well as methods suggested by other authors. Lessons learnt included providing for a long time frame, which is necessary to develop relationships and trust with individuals and their Communities,1 adopting a flexible approach and engaging cultural advisers who represent different sections of the Community.

Keywords: Indigenous research methodology, research methods, health services research, men’s health, mental health research.

Early research involving Australian Indigenous 2

people commenced with anthropological

studies that were often intrusive, demeaning and unethical. Most did not result in any lasting

benefit to the community (Henry, Dunbar, Arnott, Scrimgeour, & Murakami-Gold, 2004;

Johnstone, 1991; Smith, 1999). As a result, Aboriginal and Torres Strait Islander people,

like Indigenous people elsewhere, have grown to distrust research and researchers (Humphrey,

2001). Although, initially, there were no clear policies and guidelines into the conduct of

research involving Australia’s Indigenous people, more recently there has been a paradigm

shift in the approach to research (Henry et al., 2002; Humphrey, 2001; National Health

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and Medical Research Council, 2003; Smith, 1999). Nonetheless, literature on Indigenous

health research methodology when conducted by non-Indigenous researchers continues to

be sparse.

Over the last decade, much has changed in the area of Indigenous research. Two reports,

We Don’t Like Research, published in 2000, and We Can Like Research, published in 2008,

highlight this development (Onemda VicHealth Koori Health Unit, 2008; VicHealth Koori

Health Research and Community Development Unit, 2000). The 2008 report highlights

the need for Indigenous people to initiate and control research that involves them. However,

there continues to be many Indigenous communities where Indigenous researchers are un-

available and Indigenous communities are either ill-equipped to initiate research themselves

or their interest in research needs to be cultivated (Onemda VicHealth Koori Health Unit,

2008). In such situations, research can still be conducted by building ‘strong partnerships

between the Community, ACCHOs, research organisations and researchers’, as recommended

by the Victorian Aboriginal Community Controlled Health Organisation’s Strategic Direc-

tions Report for the Social Determinants of Aboriginal Health Project (Watson, Adams,

Fredericks, & Mahoney, 2010, p. 9).

This paper is part of a doctoral thesis and describes the methodology adopted by a non-

Indigenous student researcher to engage with the Koori 3

population in three towns in rural

Victoria. Throughout his study period, and in co-authoring this paper, the student researcher

was supported by two Indigenous advisers, one of whom was a formal cultural adviser and

the other a co-supervisor. This paper highlights the lessons learnt by the student researcher

(who is henceforth referred to as ‘the researcher’) in carrying out this methodology. The re-

search was informed by the decolonising methodology proposed by Maori academic Linda

Tuhiwai Smith as well as the Guidelines for Ethical Conduct in Aboriginal and Torres Strait

Islander Health Research, published by the Australian National Health and Medical Research

Council (NHMRC) (National Health and Medical Research Council, 2003; Smith, 1999).

Lessons learnt by other researchers who have conducted Indigenous health research in Aus-

tralia have also been employed (Henry et al., 2002; Pyett, Waples-Crowe, & van der Sterren,

2009; Waples-Crowe & Pyett, 2005). Smith (1999) states that ‘Indigenous methodologies

tend to approach cultural protocols, values and behaviours as an integral part of methodology’

(p. 15). This paper describes methodology from this Indigenous perspective and it is hoped

that it will provide some practical steps particularly for non-Indigenous researchers conducting

research among Indigenous communities (see Table 1).

52 | Qualitative Research Journal, vol. 11, no. 1, 2011

Table 1: Value-based Steps Followed by a Non-Indigenous Student Researcher in Engagement with an Aboriginal Community in Rural Victoria

TimelineValueSteps followed

Year 1Survival and Pro- tection

Familiarised himself with Aboriginal history and culture and received training in cultural competence

1

Year 1ResponsibilityConfirmed area of research need by consultation with the Koori com- munity/Indigenous experts in the field

2

Identified a promoter for the introduction of the researcher to the Community

Obtained support in the form of supervision from an Indigenous and non-Indigenous researcher from VACCHO

Year 1EqualityIdentified partners and formalised partnerships with the Indigenous community involved in the research

3

Obtained formal support from the ACCHO that would support the re- search

Identified and obtained formal support from cultural advisers

Applied for and obtained Ethical Clearance for the study

Year 2Spirit and Integ- rity

Began the process of ‘cultural immersion’ to get to know the Com- munity and allow the Community to get to know the researcher

4

Year 3RespectGradually built trust through informal interactions with the Community (‘learning while working in the community’)

5

Recruited participants for the study using snowball sampling

Years 2, 3 and 4ReciprocityGave back to the Community by:6

Respectconducting training on ‘Basics of Counselling’ for the SEWB workers

Equalityacknowledging participant contributions in publications and presenting them with copies of the work

avoiding misinterpretation of meaning by ‘respondent validation’

BACKGROUND OF THE STUDENT RESEARCHER

The researcher’s interest in Indigenous mental health grows from his previous experience in

community mental health in India and his own Anglo–Indian culture. He is an overseas

trained public health physician with previous experience in developing and running a rural

mental health service in South India (Isaacs, Neerakkal, Srinivasan, & Jayaram, 2006). The

researcher belongs to the Anglo–Indian community, which is a direct outcome of the

European colonisation of India and, in belonging to a minority community, he has a sub-

jective understanding of issues around race and identity. This background has enabled him

to better understand Australian Indigenous people and, in particular, the Koori people of

Victoria.

Anton Neville Isaacs, Hugh Pepper, Priscilla Pyett, Hilton A. Gruis, Peter Waples-Crowe & Mark A. Oakley-Browne,'‘What You Do is Important But How You Do it is More Important'' | 53

RESEARCHER’S INTRODUCTION TO ABORIGINAL AND TORRES STRAIT ISLANDER PEOPLE

The NHMRC states that research involving Aboriginal and Torres Strait Islander people

should be guided by a set of core values. One of those values is Survival and Protection. This

value highlights the need for the researcher to be aware of the history of Aboriginal and

Torres Strait Islander peoples and respect their social cohesion and cultural distinctiveness

(National Health and Medical Research Council, 2003). Being an international student

with no previous exposure to Aboriginal and Torres Strait Islander people, it was necessary

for the researcher to get to know the Community, the people and what they stood for.

The researcher obtained an introduction to the history, images and artwork of Koori

people through a visit to the Koorie Heritage Trust in Melbourne. He then attended training

programs on cultural competence both at the university as well as externally (Indigenous

Psychological Services, 2004–2011; National Health and Medical Research Council, 2003;

Waples-Crowe & Pyett, 2005; Westerman, 2004). Through teaching Indigenous health to

university students, together with informal discussions with knowledgeable members in the

field, he educated himself about the history of Australia’s Indigenous people. He was also

invited to accompany a group of university students for a period of ‘cultural immersion

training’ (Fielke, Cord-Udy, Buckskin, & Lattanzio, 2009) where he stayed with the

Adnyamathanha people in South Australia and learned from their Elders about their

dreaming stories and songs and dances of their culture. While these introductions did not

provide the researcher with specific knowledge of the Victorian community that was to be

researched, it still gave the researcher a broad introduction and valuable insight into Australian

Aboriginal people and their history.

INVOLVING THE COMMUNITY IN DECIDING THE FOCUS OF RESEARCH

From the literature, it was evident that mental health problems are common among Indigen-

ous people (Berry & Crowe, 2009; Hunter, 2003; Swan & Raphael, 1995) and that Indi-

genous people with a mental illness are reluctant to access mainstream mental health services.

Whilst this is largely thought to be due to cultural inappropriateness of services, (Kowanko,

Crespigny, Murray, Groenkjaer, & Emden, 2004; Wenitong, 2002; Westerman, 2004),

little is known about help seeking among Indigenous people with mental health problems.

Additionally, mental health services in the study area are coordinated by a single regional

hospital through community mental health centres spread across the region. Therefore, we

felt it would be feasible to focus the research on help-seeking behaviour for mental health

problems and development of strategies to render mental health services more user-friendly

for Indigenous people. With this background information, the researcher met with key In-

digenous persons from the Victorian Aboriginal Community Controlled Health Organisation

(VACCHO) who are involved in mental health and social and emotional wellbeing (SEWB)

programs. In addition to supporting the proposal, one Indigenous and one non-Indigenous

researcher from VACCHO agreed to co-supervise the research. An early outcome of these

discussions was the decision that being a male, it would be culturally appropriate for the

researcher to confine the research to Indigenous men.

We also consulted with the Regional Coordinator of the SEWB program and the staff

of the Aboriginal Community Controlled Health Organisation (ACCHO) in the region.

Another factor that contributed to deciding the focus of this research was that the then

54 | Qualitative Research Journal, vol. 11, no. 1, 2011

Director of psychiatric services at the regional hospital was also keen on supporting the re-

search. After consultation with all parties concerned, it was decided that the research would

study help-seeking among Indigenous men with mental health problems and the factors

that influence their utilisation of mental health services. Therefore, the aim of the research

was to improve mental health services for Indigenous men. In-depth interviews and focus

groups were to be conducted with participants who included staff from the community

mental health services, Indigenous SEWB workers and Indigenous men and carers.

EARLY CONSULTATIONS WITH THE COMMUNITY AND IDENTIFYING CULTURAL ADVISERS

A number of authors have stressed the need to begin consultations with the Community

involved in the research before the research proposal is developed (see Pyett et al., 2009;

Wand & Eades, 2008). One of the supervisors of the study acted as the promoter of the re-

search. His role as promoter was significant due to his previous experience as the Regional

Coordinator of the SEWB program where he had developed important networks and

working relationships with all Aboriginal communities and their respective organisations

within the region. The promoter was the key to setting the foundation for the research work.

At the outset, he introduced the researcher to the CEO of the ACCHO and to other signi-

ficant members of the Koori community, and discussed the proposed study with them in

order to obtain their opinion as well as advice on how to go about the study (Henderson,

Simmons, Bourke, & Muir, 2002). While discussing the proposed research with Community

members, an Elder poignantly remarked, ‘What you do is important but how you do it is

more important.’

It is frequently suggested that research be overseen by a steering committee consisting of

Aboriginal Elders and other significant members of the community (Henderson et al., 2002;

Pyett et al., 2009). When asked for advice regarding a steering committee, the CEO of the

local ACCHO suggested that it would be more feasible to have cultural advisers (CAs) who

could be contacted individually for advice and guidance. As part of giving back to the

community, the researcher offered to conduct education sessions for the staff of the ACCHO

as well as for the general community on any aspect of health, including mental health.

One CA was chosen from each of the three key service areas in the region. All three

agreed to support the study by recruiting participants and providing guidance on engagement

with the Community. Later, formal letters of support were received from each of them. One

of them is a co-author of this paper. Ethics approval was obtained from Monash University’s

Standing Committee on Ethics in Research Involving Humans and from the regional hos-

pital’s Human Research Ethics Committee.

‘LEARNING WHILE WORKING IN THE COMMUNITY’ AND RECRUITMENT OF PARTICIPANTS

Snowball sampling was used to recruit participants (Patton, 2002). Although CAs had initially

agreed to introduce the researcher to potential participants, the process took a long time.

Recruitment took place mostly during Community gatherings, where Koori men surrounded

by their own people felt comfortable enough to talk to outsiders. Such gatherings were in-

frequent. They usually occurred during NAIDOC week celebrations (National Aborigines

and Islanders Day Observance Committee week is celebrated in the first full week in July

Anton Neville Isaacs, Hugh Pepper, Priscilla Pyett, Hilton A. Gruis, Peter Waples-Crowe & Mark A. Oakley-Browne,'‘What You Do is Important But How You Do it is More Important'' | 55

each year ‘to celebrate the history, culture and achievements of Aboriginal and Torres Strait

Islander people’) and during the week of the Walks for Reconciliation (organised by Koori

communities during National Reconciliation Week, which is held between 27 May and 3

June every year) to support action towards reconciliation between Indigenous and non-In-

digenous people in Australia (NAIDOC 2011; Reconciliation Australia 2010). The process

of recruitment at some of these events is discussed below. Community members who had

enough time to get to know the researcher were more forthcoming about participating than

others.

One CA advised that in order to recruit participants for the study, the researcher needed

to attend Community gatherings. This process has been described as ‘learning while working

in the community’ where the researcher participates in community life and events in order

to develop social skills and understanding of the Community’s culture (Pyett, Waples-Crowe,

& van der Sterren, 2008). The researcher therefore attended every get-together of the local

Aboriginal community that he was invited to and made multiple courtesy calls to the different

services run by the ACCHO. The promoter initially accompanied the researcher on these

visits until he felt comfortable going on his own.

The process of engaging with the Community was slow and occasionally bumpy. In the

second year of the research, the researcher was invited to the flag-raising ceremony for

NAIDOC celebrations at the local Koori meeting place. Having arrived at the venue early

and noticing that his CA had not yet arrived, he walked up to a group of Koori men and

introduced himself. In no time, all of them departed, save one, who then said to him:

You see all of them walked away? You never walk into a group of Koori men and talk to them

unless you know them. Stand aside and wait until they call you. Koori people will never talk

to you unless they know you. Remember this always.

To ensure that his interview questions were sensitive and appropriate, the researcher

conducted practice interviews with his CAs. Although the three CAs had approved of the

explanatory statement prepared specifically for Indigenous participants, practice interviews

helped the CAs to better understand what the process was about and gave them more con-

fidence in introducing the researcher to other men. During the course of the next twelve

months, the researcher attended many funerals, had multiple meetings with his CAs and

recruited a few more men for the study. On the invitation of the ACCHO, the researcher

also conducted a basic course on counselling for their SEWB and drug and alcohol workers,

which was well received. As part of the research, the researcher had incorporated artwork of

a local Koori artist in a poster for which he won a prize. A copy of the poster was formally

presented to the artist in the presence of his CA and another Elder. Each of these activities

demonstrates the core values of Reciprocity, Respect and Equality (National Health and

Medical Research Council, 2003).

An invitation to a men’s golf day outing in the second year had provided a promising

opportunity for the researcher to meet and recruit men for the study. However, heavy rain

led to its cancellation and it was another 12 months before the event was rescheduled and

the researcher was able to attend. By this time, he had developed a friendship with his CA.

Since the researcher had not played golf before, he was given his first lessons by a Community

Elder, and in playing as part of a team he was touched by their generosity, patience and en-

couragement. Following the game, as the researcher was about to leave, his CA invited him

to the cultural program scheduled for the following day. He said, ‘Come if you can. You

are part of the Community now and you know that the doors are always open’. Another

56 | Qualitative Research Journal, vol. 11, no. 1, 2011

sign of his acceptance was when men held their hand up to lock his in a ‘Koori handshake’,

which the researcher learnt from an Elder.

The researcher made regular phone calls to his CAs to enquire about potential participants.

During one such call, his CA asked him to drive over to a local park where a Koori expo

was taking place. There was a gathering of about 200 members of the community there and

he introduced the researcher to a few men who agreed to be interviewed. On another occasion,

the researcher was invited to participate in the Reconciliation Walk. At the end of the walk,

while people were having their barbecue lunch, his CA introduced him to a group of men

who readily agreed to participate, giving him their phone numbers. One of the men was a

local Elder. At the end of the interview with this Elder, which was conducted later, he sug-

gested that he would accompany the researcher to some houses and talk to people whom he

knew. He said that his presence would enable the men to feel comfortable talking about

their problems. Two men were recruited that way. Three others were not home that day.

One male Elder who agreed to participate was unable to keep his appointments on three

occasions because of deaths and funerals.

A total of 12 Indigenous men and carers were recruited for the study, most of whom

were from the one community (17 km from where the university department is located).

Recruitment was less successful in the two communities that were further away from the

university (81 km and 149 km) and in situations where people did not get enough time to

be acquainted with the researcher.

DISCUSSION

Conducting field research within Aboriginal communities can be quite challenging, especially

when initiated and carried out by a researcher who is non-Indigenous and an outsider. This

paper has demonstrated that research of this nature is possible when the researcher is able

to exhibit a culturally appropriate and sensitive attitude towards the research, adheres to the

right values and protocols and is respectful to the Koori community. The research demon-

strates reflexivity, which is an important prerequisite for Indigenous research (Henry et al.,

2002; Nicholls, 2009). The researcher demonstrated that he learned from his CAs and the

Koori community to be patient and flexible, utilising opportunities that were presented by

invitations to Community events. The promoter played a major role in introducing the re-

searcher to the Community.

Although the authors had taken all precautions to ensure that the research was respectful,

recruitment of participants in two Communities was less than ideal. This was primarily due

to the lack of time, an issue raised by other authors as well (Couzos, Lea, Murray, & Culbong,

2005; Mayo, Tsey, & Empowerment Research Team, 2009; Shahid, Bessarab, Howat &

Thompson, 2009). Providing an adequate time frame for the research allows for a relationship

to be built between the researcher and the Indigenous community (Waples-Crowe & Pyett,

2005; Mayo et al., 2009). For a community-based research project of this size and scope

and involving Indigenous communities with little research experience, we feel that five years

would be an adequate time frame rather than the three years allocated to a PhD project.

Another likely reason for recruitment difficulties was the stigma usually associated with

mental health problems, which is intensified in Indigenous communities where ‘shame’ ex-

acerbates peoples' reluctance to discuss such private matters with service providers, or other

outsiders such as researchers.

Anton Neville Isaacs, Hugh Pepper, Priscilla Pyett, Hilton A. Gruis, Peter Waples-Crowe & Mark A. Oakley-Browne,'‘What You Do is Important But How You Do it is More Important'' | 57

CAs were an integral part of this study. Without their support and encouragement, this

study would not have been possible. One of the shortcomings of this research was the inad-

equate number of CAs. We learnt that it would have been useful to have more than one CA

for each Community. The CAs in this project did not receive any reimbursements for their

time and effort. Since CAs are otherwise busy people, advising student research presented

an additional burden without financial or other reward (Shahid et al., 2009). Community

Elders, in particular, who accept the role of a CA, bring with them a vast body of experience

that could significantly enrich the research process. Perhaps, if they were considered part of

the supervisory team and made eligible for remuneration, just as their academic counterparts,

the research would demonstrate more Equality.

In order to be accepted by the Community, the researcher needs to first be accepted by

the CAs and develop a relationship with them. That requires patience and flexibility, qualities

that will go a long way in engaging with the Community as well. Repeated postponements

of appointments must be accepted by researchers, as family and community gatherings as

well as funerals are a priority for Koori people. Crespigny and colleagues have also noted

that flexibility was a key factor in their success with developing partnerships for Indigenous

research (Crespigny, Emden, Kowanko, & Murray, 2004). Since this was the first time re-

search involving cultural advisers was carried out in our study region, they required time to

determine that the researcher was respectful and that the research was outcome-oriented

before committing to engage with the researcher and the research process. Once the process

of recruitment and interviews commenced, participants generally discussed their experience

of the researcher with the CA. CAs relied on participant feedback to reassure them that the

research process not only did no harm but was also of benefit to the Community. This was

also an opportunity for the CAs to learn about the research process.

A useful way of getting to know the Community is by attending gatherings such as those

that take place during NAIDOC week celebrations. One needs to approach the research

with respect, understanding and empathy for what Koori people have endured over the

years. In engaging with Koori people, one also learns the value of humour, which is an en-

dearing characteristic of their culture and a mark of their resilience and survival. Koori people

are a good judge of character and integrity in a person because as one of the CAs stated,

‘They have had to do it all their lives to figure out where they stood with outsiders’. Respect

is a very important value in the Koori community and the researcher needs to demonstrate

this at all times. Furthermore, when discussing sensitive issues such as mental health with

men, a little smile or the ability to share a laugh with them can go a long way in developing

mutual trust.

CONCLUSION

This paper gives a detailed description of how a non-Indigenous researcher built a research

relationship with an Indigenous community, starting from early consultations to writing up

a collaborative research paper with two Indigenous co-authors. It highlights some key elements

that non-Indigenous researchers need to consider when conducting research involving Indi-

genous men. They include providing for a long time frame for the research, obtaining the

help of an appropriate promoter to facilitate introductions to the community, identifying

the right cultural advisers and being flexible and respectful at all times. It is hoped that the

processes set up and the partnerships developed through this research will pave the way for

long-term collaborations focused on improving Indigenous health and wellbeing in the region.

58 | Qualitative Research Journal, vol. 11, no. 1, 2011

More culturally appropriate research that takes care of the aspirations and needs of Aboriginal

people will go a long way in changing their opinion of research and perhaps even encourage

them to embrace it.

ACKNOWLEDGEMENTS

The authors acknowledge Ramahyuck District Aboriginal Corporation under whose auspices

AI’s research is being conducted. AI wishes to thank his cultural advisors, Hugh Pepper,

Phil Perry and Larry Levi as well as Indigenous community members Wayne Thorpe and

Laurie Marks for proofreading the manuscript. The authors also thank Associate Professor

Marlene Drysdale for her comments on the manuscript.

NOTES 1 An Aboriginal community includes country (land), family ties, belonging and shared experiences of

Aboriginal people. The term ‘Community’ has been used with a capital C when it refers to this context.

2 In this paper, the term 'Indigenous' is used interchangeably with 'Aboriginal and Torres Strait Islander'.

3 Koori (also spelled ‘Koorie’) refers to the Aboriginal people of Victoria and south-eastern Australia.

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