Culturally safe research process in mental health

1.1 Cultural safety

The term cultural safety was first coined by Māori, in the context of inequity in mainstream health care services in Aotearoa, New Zealand.^17, 18 Cultural safety involves understanding dynamics of power relations in and between cultural groups,⁶ and it requires culturally appropriate health care practices, which empower Aboriginal and Torres Strait Islander communities.¹⁹ Culturally safe health care practices take into account culturally relevant concepts of health, which include spiritual balance and community well-being as well as physical and psychological well-being.²⁰ This requires consideration of the social and emotional well-being of Aboriginal and Torres Strait Islander peoples, as well as historical, political, and social determinants of well-being. These include connection to land, culture, spirituality, and ancestry; kinship; self-determination; community governance; and cultural continuity.^21, 22

Just as health and mental health practice need to be culturally safe,²³ any research which impacts Aboriginal and Torres Strait Islander peoples must be done in a culturally safe manner.^9, 24 Culturally safe research empowers Aboriginal and Torres Strait Islander voices, it involves authentic partnerships with communities, and is led by Aboriginal and Torres Strait Islander peoples.⁶ Culturally safe research also requires non-Indigenous researchers to reflect on their own cultural identity and relative power and privilege in society.²⁴

This self-reflexivity is especially important given the historical context of unsafe and exploitative research done ‘on’ rather than ‘with’ Aboriginal and Torres Strait Islander peoples.⁸ Non-Indigenous people have often done research relating to Indigenous peoples without prior consent, meaningful engagement or access to results or benefits of the research.^3, 25, 26 Indeed, research has historically been used to justify dehumanising, and oppressive policies and practices.^3, 25 Therefore, when non-Indigenous researchers are working in research with Aboriginal and Torres Strait Islander peoples, they need to work in a self-reflective manner, to be aware of biases shaped by dominant ways of knowing and engage in ongoing critical reflection.^24, 27–29

1.2 The current research

The Transforming Indigenous Mental Health and Wellbeing project (https://timhwb.org.au/) is an example of a wide-reaching research program which follows an Indigenous and decolonising research approach. In this paper, we describe a project which forms part of the wider research program. This project ultimately aims to improve cultural safety in mainstream mental health services for Aboriginal and Torres Strait Islander peoples, by developing guidelines for Culturally Safe practice (see Figure 1). Here, we will focus on how the first phase of this project was conducted in order to establish a culturally appropriate research foundation.

To ensure that the results from this project are meaningful to Aboriginal and Torres Strait Islander peoples, the process of arriving at results needs to be culturally safe and appropriate.¹⁰ For example, Harfield et al (2020) recommend considering whether the research responds to a need determined by communities, whether community members were engaged and consulted appropriately, and if the project was led by Aboriginal and Torres Strait Islander peoples. While one aim of our broader research project was to consult with community members to co-design a qualitative interview schedule, the process of how the research questions were designed, how focus groups were conducted, and how this knowledge was interpreted and disseminated are key factors to consider.¹⁰

Consistent with an Aboriginal Participatory Action Research (APAR)⁸ methodology, our Aboriginal-led research project was designed to be conducted in phases, using an iterative approach. This approach was adopted to ensure flexibility to align with community needs, relationship building with Aboriginal and Torres Strait Islander peoples and communities, and the integration of Indigenous knowledges into every stage of the research process. This approach is also consistent with the NHMRC core values for ethical research (spirit and integrity, cultural continuity, equity, reciprocity, respect, and responsibility).

Phase 1 focused on the co-design of a qualitative interview about experiences of cultural safety in mainstream mental health services with Aboriginal and Torres Strait Islander peoples. Phase 2 focuses on the delivery of this interview to a broader group of Aboriginal and Torres Strait Islander peoples (see Figure 2). This paper describes the process of designing and implementing the first phase, which enabled a culturally safe approach to the second phase of our project.

In summary, the aim of this paper is to highlight the significance of a culturally safe research process. We will describe an example of working with Aboriginal and Torres Strait Islander community members through a co-design process as a necessary first step towards improving cultural safety in mental health services, where the process of how the research is done is an outcome in itself. We acknowledge that while this is one example of a culturally safe research process, it is not the only ‘correct’ process. Indeed, in an effort to decolonise research methodologies, fixed conventions and methods are not necessarily helpful.¹¹

2.1 Indigenous governance

In line with Aboriginal Participatory Action Research methodologies,⁸ this project was led and governed by senior Aboriginal and Torres Strait Islander researchers and clinicians,^30–32 who were working closely with non-Indigenous researchers. The team established an Aboriginal Advisory Group made up of Aboriginal chief investigators on the project to determine the research questions, and to advise on how to consult with community organisations and community members, as well as on how to construct questions and topics for the focus group yarning sessions. For example, to begin with, we asked partner organisations what we can do to help them, in line with our governing cultural principle of reciprocity (e.g., visit community partners on Country to present our research proposal).

2.2 Training for non-Indigenous staff

The collaboration between Aboriginal and Torres Strait Islander researchers and non-Indigenous researchers is likely to be common among research teams working on issues that impact Aboriginal and Torres Strait Islander peoples. Therefore, it is important for non-Indigenous research team members to be trained to work in culturally safe ways with Aboriginal and Torres Strait Islander peoples. However, it is also important that the entire responsibility of training non-Indigenous researchers does not rest with Aboriginal and Torres Strait Islander members of the team. Below, we describe the process through which our non-Indigenous team members were trained at the onset of the research program.

Learning how to work in a culturally safe way is an ongoing process,³³ and what we describe here is what was done in the early phase of the project. Further, non-Indigenous researchers were provided with cultural awareness training, as a first step towards improving cultural sensitivity and cultural safety, by attending two workshops about the ‘Dance of Life’.³⁴ The Dance of Life model is a framework which provides avenues for understanding mental health, health, and well-being among Aboriginal and Torres Strait Islander peoples via trauma-informed, and culturally relevant mediums which consider social and emotional well-being.

Non-Indigenous researchers also participated in a Cultural Exchange Program, with a group of Elders, which involved meeting and sharing a meal, over six, 4-h sessions. The aim was for team members to begin learning how to work with Aboriginal and Torres Strait Islander peoples in culturally safe ways. These sessions were facilitated by a senior Aboriginal community researcher, who created a safe space. The purpose of this program was to facilitate self-reflexivity, cultural understanding, and respect in the group of non-Indigenous researchers. For example, it is crucial for non-Indigenous researchers working in this field to understand how Western-trained researchers bring biases to research, and the contribution of colonial research methodologies to Indigenous disadvantage.^{27, 29, 35, 36}

The Cultural Exchange Program was developed, led and run by Aboriginal people, and encouraged an immersive and relational process between the non-Indigenous participants and Elders, in line with Aboriginal ways of knowing, being and doing.³⁷ In this context, the program moved beyond basic cultural awareness training, and allowed for listening, learning, and storytelling. Elders and the Aboriginal community researcher were appropriately compensated for their time, skills, and knowledge sharing.

2.3 Co-design process and ongoing community engagement

As an initial step, two workshops were held where Aboriginal and Torres Strait Islander research team members discussed the concept of cultural safety, how it applies to mental health services, what kinds of questions could be presented in the Phase 1 focus groups, as well as how the focus groups could be conducted. For example, while broad and specific questions were discussed, there was agreement that there needed to be flexibility in how the questions should be adapted if required during any given session.

We presented our research proposal for Phase 1 and 2 to Aboriginal and Torres Strait Islander community partners, and the relevant sub-committees in charge of approving research projects for each region. This process confirmed that the research met the needs of the relevant communities and began the process of relationship building with these communities. This process also allowed us to incorporate region-specific feedback into our research proposal, which guided the development of the questions that we asked the focus groups in Phase 1 of the project, and how we went about asking these questions. Below, we detail the process of running these focus groups.

2.4 Ethics

The project was designed in accordance with the NHMRC guidelines for ethical research⁴⁰ and the appropriate process for applying for ethics approval was followed. Ethics approval was received from WAAHEC (WAAHEC: HREC1037).

3.1 Process as the outcome

3.2 Co-design of qualitative interview

The process of conducting focus groups, and the results of focus groups, together informed the qualitative interview to be used in Phase 2 of this research project. First, participants highlighted the benefit of administering the interview in small groups as well as allowing for more than one opportunity to talk about experiences. Second, participants noted the importance of creating a safe space to discuss sensitive topics, such as mental health. Third, researchers must allow enough time for rapport building, and the choice of facilitator/interviewer was emphasised. We were also advised to use a yarning methodology, and to allow for regular breaks. In terms of how data is collected, feedback from the focus groups revealed that it is more culturally appropriate to follow qualitative research methods to record the experiences of Aboriginal and Torres Strait Islander peoples, as narratives and storytelling are culturally relevant mediums for sharing knowledge. Furthermore, some responses (e.g., from Cultural Healers) were represented through artwork and drawings, as visual representations of concepts around mental health and cultural safety. This is consistent with culturally appropriate research and data collection methodologies which have been outlined.^9, 38, 43

We will use the results from this phase to inform our research moving forward, in Phase 2. Specifically, we will use these results to co-design a qualitative interview under the guidance of an Aboriginal reference group and continue to consult with Aboriginal and Torres Strait Islander experts on our research team, and community partners.

4.1 Critical reflections

On reflection, the research team proposed the following ways the process of conducting this project could have been made more culturally safe. Firstly, smaller groups (5–6 people) may have provided some people with more of a chance to talk about their experiences, compared to what we generally had (8–10 people). However, groups with fewer than 4 people would not provide the diversity of experiences that we were hoping to understand.

Second, we could have spent more time building relationships with participants from one region, where we did not spend as much time as the others. Perhaps we could have made two visits instead of one, and spent more time on the first visit understanding the current context of the community, and adjusted our schedule and plan accordingly.

Finally, while we met NHMRC guidelines to conduct this project ethically, the research project, as well as the ability of non-Indigenous members of our research team to produce higher quality research would have benefited from more Aboriginal participation at the researcher level. For example, while participants confirmed that our summary of the focus group results was an accurate reflection of their voices, the data analysis, interpretation and summary of the focus group results could have been made richer from additional workshops with the Aboriginal reference group.

Research has directly contributed to discrimination and colonisation, and it is therefore particularly important that academic workplaces support Aboriginal and Torres Strait Islander participation in research. This includes through recognising and including Aboriginal and Torres Strait Islander knowledges, and building the capacity of Aboriginal and Torres Strait Islander community researchers. Indeed, a position statement published by the Australian Psychological Society¹⁶ illustrates how Indigenous research methodologies and experiences are more accepted, then engagement in research, as well as recruitment and retention of Aboriginal and Torres Strait Islander researchers will likely increase. This highlights the need for greater cultural safety of academic workplaces in general.