“Got to build that trust”: Aboriginal Health Workers’ perspectives and experiences of maternal oral health

Background Aboriginal Health Workers provide a unique insight into understanding the health needs of the Aboriginal peoples in the community on account of their cultural knowledge, experiences and understanding of the health services. The aim of this study was to explore the perceptions and experiences of Aboriginal Health Workers towards oral health care to inform the development of an oral health care program to better meet the oral health needs of Aboriginal pregnant women and new mothers. Methods A participatory action research methodology informed the study. Focus groups were conducted with Aboriginal Health Workers at two antenatal health services in Sydney, Australia. Results A total of 14 people participated in the focus groups. The four themes that emerged from the focus groups provided insight on the importance of trust in the building of empowering relationships with Aboriginal women and highlighted the need for Aboriginal Health Workers to receive additional training to better address the oral health needs of Aboriginal pregnant women and new mothers. However, the Aboriginal Health Workers worked in a system fundamentally driven by the legacy of colonisation and integenerational trauma that has created systemic barriers to access of health services, including dental care. The participants recommended that a priority dental referral pathway, that supported continuity of care, could provide increased accessibility to dental care for Aboriginal pregnant women and new mothers. Conclusions The oral health of Aboriginal pregnant women and new mothers is supported by Aboriginal Health Workers, who outlined both a systems and an

individual approach in delivery of existing dental care. The Aboriginal Health Workers provided recommendations to develop a program of dental care that could break down the systemic factors that create barriers to accessing dental care for Aboriginal women.

Background
Passing on knowledge verbally through yarning (speaking) is increasingly recognised among Western research paradigms as a culturally competent Indigenous research method (see glossary, Appendix 1). [1][2][3][4] However, this research method is not new as it has been practised, in various forms, for thousands of years by Indigenous peoples (Appendix 1) globally and is central to the exchange of knowledge among Aboriginal and Torres Strait Islander Australians (hereafter referred to as Aboriginal Australians, see Appendix 1). [5] Aboriginal ways of knowing, being and doing takes a strengths-based approach to building communities by creating a sense of identity, connection, community and kinship, which are often consolidated by building relationships through yarning. [6] In stark contrast to Aboriginal peoples' ways of doing, Western research frameworks and methods often tell a story about Aboriginal Australians that emphasises poor health, highlighting inequities in health outcomes with respect to morbidity and mortality on almost every measure of life. [7] Moreover, these indicators tend to highlight a more superficial story about the health of Aboriginal peoples. What Western measures of Aboriginal Australian health and wellbeing typically overlook are the issues resulting from the cumulative effect of colonisation and intergenerational trauma associated with policies leading to the Stolen Generation (Appendix 1), both being key social determinants of health. [8] A step towards decolonisation (Appendix 1) of this Western paradigm could be achieved by the valuing and engaging with the strength of Aboriginal Australians' methods of knowledge exchange, such as through oral traditions like yarning. [9] A systematic review undertaken by Kong et al. [10] indicated that a wide range of psychosocial factors, such as education, income, experiences of racism, social support and other priorities, affected the decision of pregnant Indigenous women globally to access the dentist or brush their teeth, which can ultimately affect the mother's oral health and the wellbeing of the baby. The place of residence and the existence of culturally competent dental services, with coordinated support from a midwife or antenatal care provider, were important contextual factors that seemed to positively influence pregnant Indigenous women's oral health behaviours. [10] Workers (AHWs), already work with mainstream health services and have a long history in bridging the gap between an Aboriginal person and a health service; AHWs often play a major role in facilitating access to services for the local Aboriginal community. [18] Although some AHWs provide dental care to children and adults in some remote communities, no specific programs have been developed to build capacity of Indigenous Health Workers globally to promote oral health among Indigenous pregnant women specifically, [19] leaving a gap in workforce development. This study aimed to understand the stories, experiences and perceptions of AHWs towards oral health care to inform the development of a program to better meet the oral health needs of Aboriginal pregnant women and new mothers in the community.

Methodology
Participatory action research (PAR) was used as an overarching framework to explore how best to address the oral health needs of Aboriginal pregnant women and new Aboriginal mothers. In PAR, local people participate in the research process to identify and reflect on existing issues to develop appropriate solutions. [20] In the context of Aboriginal Australians, who have traditionally been researched "on" instead of "with", [21][22][23] PAR methodology ensured the research involved collaboration with AHWs, and therefore, identifies changes that would be acceptable for AHWs within antenatal services.

Conceptualisation of study design
One of the main principles of PAR is to equalise the power relationship between the "researcher" and the "participant". [20] Through yarning with the AHWs we collectively identified that poor oral health among Aboriginal pregnant women and mothers was an area of need for the community. The AHWs also expressed some desired outcomes of the project (for example, developing an antenatal dental care training program), identified how they wanted to be involved in the project (through a focus group and periodic informal meetings for brainstorming and decision making) and specified that conducting focus groups among the AHWs, followed by interviews with Aboriginal pregnant women, to be the most appropriate methods of data collection for this study. These initial yarns were also important to cultivate trust between the AHWs and the lead author (AK), who identifies as a non-Indigenous woman raised in Australia, and who was the facilitator for the focus groups.
facilitated by two of the study authors (AK and LR), where LR also wrote field notes.
LR is a qualitative researcher with experience working with vulnerable populations.
The subsequent two focus groups were facilitated only by AK, who also wrote field notes after the focus groups. All of the focus groups were audio recorded with consent from all participants. The recordings were transcribed by a professional service and checked for accuracy by AK, who wrote additional memos while listening to the transcripts.

Analysis
An inductive thematic analysis based on the work of Braun et al.
All participants were assigned pseudonyms to ensure confidentiality. AK read and re-read the transcripts and listened to the audio recordings and accompanying field notes and wrote additional memos to ensure adequate immersion in the data. AK initially coded the transcripts inductively using NVivo Software. AK then generated themes by clustering similar codes together. AK revisited these themes a second and third time to better understand the themes from each focus group, and then combined themes across all focus groups. These themes were reviewed by another non-Indigenous researcher with experience in qualitative research (MSS) and by an Aboriginal researcher (FT). After agreement between AK, MSS and FT, AK presented the themes to the AHWs who had agreed to be contacted again. AK yarned about the emerging themes and provided a written copy of the themes, allowing for member checking to confirm the interpretation of the analysis and ensure rigour of the findings.
[25] All participants were invited for a follow-up focus group to check interpretation, however only half of the participants (n=7) were available due to unforeseen changes with client scheduling. This discussion refined the concepts underlying each theme and the language used to define the themes.

Results
Four main themes emerged from the focus groups (Table 1) relating to AHW's perspectives and experiences of maternal oral health care. All findings around the scope and future design of an antenatal oral health program will be published elsewhere.

Theme 2: Colonisation & intergenerational trauma: systemic barriers
The long-term effects of colonisation and intergenerational trauma, which affected their clients' desire and ability to engage with services and institutions, were discussed by all focus groups. The AHWs identified that the cost of private dental appointments, issues with transport, long-waiting time for a dental appointment, dentists refusing to treat pregnant women, ineligibility to access public dental services or ACCHS dental services and systemic racism as external barriers to Aboriginal women accessing dental services. Additionally, the AHWs discussed that 'shame', alongside feelings of fear, anxiety and being judged during a dental appointment, were interpersonal factors that could affect an Aboriginal woman's 13 desire to visit the dentist.

External barriers to accessing dental services
In response to a question about how many Aboriginal pregnant women (out of ten) had dental problems, one participant said "I've had two" (Melissa, AHW), whereas others agreed that the number was closer to "six to eight" (Rachel, AHW) out of ten.
However, another two participants agreed that about only "one to two" (Melody, AHW) actually end up attending a dental appointment.
Cost, transport, long-waiting lists and dentists who refused to treat pregnant women were cited as some reasons for poor uptake of dental services. However, the AHWs also attributed a number of policy-related barriers arising from colonisation and intergenerational trauma. The participants reiterated the barriers to accessing both mainstream public dental services and ACCHS. In mainstream dental services, a Health Care Card (concession card) is required to access public dental services; however, not all Aboriginal women qualified for this card if they were on a higher income. Furthermore, for Aboriginal pregnant women and mothers who were on a higher income, money was prioritised elsewhere.
Because I earn over the threshold, you don't get the free dental. (Emily, AHW) the Health Care card is the biggest issue. If they're still working while they're antenatal -they can't go and access [the public dental service] because they're still getting paid…They just can't financially afford to go to a dentist, but then on a higher income -because of choices of buying a home which is what we want to do… (Louise, AHW) Accessing mainstream dental services were also problematic because of the systemic racism within institutions that manifested in difficulties engaging with institutions.
T h a t [ i n s t i t u t i o n s ] g o e s h a n d i n h a n d . Yeah, I think informal as well. I mean, we did do little in-services. We do do inservices on dental, so it could be some formal as well…I would be up for it [formal training] (Emily, AHW) Several AHWs already had some knowledge of the effect of pregnancy on a woman's oral health and vice-versa and understood the importance of a healthy diet for the mother's and baby's teeth. Several participants already encouraged women to see the dentist. In one of the services, the AHWs also handed out dental products to families. If the client hasn't seen a dentist in a while, we usually ask them when was their last dental check-up. (Melissa, AHW) So when we're talking about any good foods, we talk about the type of food you do that are better for your teeth rather than the sugary ones and the soft drinks and all that. The mums and dads are hearing that as well so we do access some other pregnant ones and we talk to them about that because it becomes a part of nutrition as well when they're pregnant. About if you're having a lot of soft drinks which are high caffeine and high sugar that's going through to bub. (Louise, AHW) I know with some of our clients, that we've gone out and some of the content we've -it's touched on the oral health, we've given, like in the gift packs, we've given out The findings from this study emphasised that building trust with the clients was a priority for the AHWs as they provided support for clients to make informed decisions about their health. Although the AHWs had cultural expertise and knowledge, trust still took time to build with clients. As discussed by Karina and Lastly, the AHWs in this study drew attention to a number of recommendations and gaps relating to Aboriginal pregnant women and new mothers receiving dental care.
Although building trusting and empowering relationships with clients were a necessity among the AHWs, the dental and broader health systems the AHWs navigated had both historical and existing barriers that prevented engagement for some Aboriginal women. On a systems level, dental services need to provide increased accessibility and continuity of care for Aboriginal women.
Despite the strengths, there were some limitations in this study. The AHWs involved in this study worked in an urban area therefore the challenges and perspectives of AHWs working in regional or remote areas were not identified. Moreover, as every Aboriginal community is distinct and diverse, the perspectives of the AHWs from this study are not intended to be representative of other AHWs.

Conclusions
The AHWs from this study provided insight on the complexities and factors that Availability of data and materials The data used and/or analysed for this study are available from the corresponding author on reasonable request.

Competing interests
The authors declare no competing interests. contributed to the conceptualisation of the study.