Theme 1: Trust builds empowered relationships
The AHWs and FPWs from all the focus groups identified the need to build trust with their clients to ensure that they could give appropriate support to Aboriginal pregnant women and mothers during the antenatal period.
Building trust
Trust was discussed as an imperative to understand their clients’ needs and priorities. Trust was something that required both time and empathy to build through the practice of yarning. Some FPWs and AHWs drew on their personal experiences to cultivate this trust.
Trust. Got to build that trust. (Melissa, FPW)
It's totally up to them and what they want. We tend to find that if we just sit there and have a yarn with them rather than push them. We find a lot of services do try and push, you known like, to tell the girls what to do. We don't do that: and we find we get better outcomes when we don't do that. (Karina, FPW)
But it's also too with that rapport building is that those yarns that you're having with your clients aren't about this is what you're doing, it's about you giving them your experience as well. So, you know, it's like, I've done this too. (Tess, AHW)
Reflecting on the importance of trust, both groups found that Aboriginal pregnant women and mothers tended to be more receptive to contact from AHWs or FPWs compared to nurses.
Often, at times, when they're in crisis and they don't answer the phone calls to the nurses, all it takes is one phone call from us and then we're back on board with them…when we contact them they're usually pretty honest with us about what's going on with them. (Sarah, AHW)
We basically just support the nurses. Already questions that the client might have. Sometimes they …direct the questions at us rather than the nurse. We just bounce off one and another and just support, you know, what we’re delivering (Karina, FPW)
Supporting women to make healthy choices
Following the discussion about the importance of building trust, the AHWs spoke about offering options and providing support by ensuring that the clients’ needs were addressed. Regardless of whether this support was psychosocial, practical or both, the participants spoke about how this approach addressed some of the barriers that affected women’s access to services.
Yes, and I actually just tend to ask, do you have somebody you can go with or do you feel okay doing this, um, or are you all right to make the call? Or if you haven't got credit, do you need to use my work phone or do you want to wait until you've got credit? So always giving options or if they've got ideas, well what do you think? So they'll let us know if they can't do that. (Louise, AHW)
it depends on where the mum is at, I guess. I'll say it that way… Yeah, their ability to access, whether they're comfortable calling, because I'll call for some clients… We do provide transport if we need to as well. (Emily, AHW)
When asked a question about the nature of the relationships the AHWs and FPWs had with their clients, some of the participants described themselves as being the connectors, interpreters and the first point of contact for many clients.
I guess we're that connector, we're the connecter with a system that is different traditionally to what some of our systems would be or would look like. So we help break down the barriers of, um, an institution which has historically been, um, one that's had a negative attachment to it from past policies and history. (Louise, AHW)
So it's kind of like - I think of us as…friendly – not a friend. Um, we look after their cultural stuff, you know, to help support them with culture? Um, we're the link between mainstream and Aboriginal people and Aboriginal culture stuff. We're kind of like interpreters as well? Because a lot of clinical stuff is a lot of jargon, so we, um, will explain it in a different way. We advocate – [emphasised] a lot. (Emily, AHW)
Theme 2: Colonisation & intergenerational trauma: systemic barriers
The long-term effects of colonisation and intergenerational trauma, which affected clients’ desire and ability to engage with services and institutions, were discussed in all focus groups. The Aboriginal staff spoke about the barriers for clients to access dental services. These barriers include the cost of private dental appointments, transport, dentists refusing to treat pregnant women, long-waiting time for an appointment in public and ACCHS dental services, ineligibility to access ACCHS (Aboriginal community controlled health service) dental services, and systemic racism. The participants also identified that ‘shame’ (see glossary, Appendix 1) which accompanied feelings of fear, anxiety and being judged during a dental appointment, were factors that could affect an Aboriginal woman’s desire to visit the dentist.
External barriers to accessing dental services
The Aboriginal staff also estimated how many of their clients (out of ten) would have dental problems during pregnancy. One participant said “I’ve had two” (Melissa, FPW), 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, and dentists who refused to treat pregnant women were cited as some reasons for poor uptake of dental services.
They're thinking they have to go private and they don't have money. (Sarah, AHW)
It's quite hard - especially if you don't drive and you have to catch public transport. (Tess, AHW)
Oh, I'll share a story. When I was pregnant with my last one, my tooth was actually bad up the back, and I went to the dentist and they refused to touch it because I was pregnant (Rachel, AHW)
Some staff also shared personal experiences or knowledge of the long waiting lists to access public and ACCHS dental services.
I went privately. I was like I need to get this out. It was killing me. I've had a wait list over at [ACCHS dental service], because I went to [ACCHS dental service] …but then the wait list to get my tooth removed was like a year? (Ellie, FPW)
If you don't want to pay, like the waiting list for the one at [public dental service], for example. [exasperated sigh] (Teigan, FPW)
The participants spoke about the need for a Health Care Card (concession card) 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)
The participants also spoke about clients avoiding contact with government institutions. One person spoke about how negative experiences create fear and become a deterrent for families to access government services. This staff member explained that even if these experiences were with one institution, the fear creates a spill-over effect in engaging with any government institution.
That [institutions] goes hand in hand. [with racism] (Sally, AHW)
There are so many complexities sometimes that it's really difficult for families to engage with Centrelink to chase that. They might have previous debt. They might have a child that's come, that's left their care, and they're backwards and forwards and it's all too hard to go into Centrelink and negotiate in that space. So that whole fear of institutional contact is...So it’s the fear of going in and having to deal with that entity, that institution, that’s why Aboriginal families prefer that outreach contact. (Jennifer, management staff)
However, five participants explained that since ACCHSs provide free dental services for Aboriginal Australians, some non-Aboriginal peoples identify as being Aboriginal to access these services.
Dental's one of them. That's why they're [people who didn’t identify previously as Aboriginal] identifying, so they can get free access to it. (Karina, FPW)
Due to this, some ACCHS require ‘confirmation papers’ (Confirmation of Aboriginality) (see glossary, Appendix 1). Participants identified confirmation papers as a barrier for many clients, especially if the client was disconnected with their family because of policies leading to the Stolen Generations.
That's why it's harder to get the confirmation now, because people were just going and using names and getting their confirmation, where now you need to go to these meetings and it is harder... But then it's harder for people that are from Stolen Generations and don't have - and are disconnected with their family. It's just so - it's just all a big mess. (Ellie, FPW)
The participants described the process of acquiring Confirmation of Aboriginality to be a long process. After applying for the Confirmation, some Aboriginal applicants would be interviewed in front of a community board which could comprise members of the Aboriginal Land Council or another Aboriginal organisation responsible for issuing the confirmation paperwork.
That is pretty much - there's nearly a 12-month waiting list. So you fill in your application form, hand that in, then ... once it's your turn they'll send you a letter and say this is the day and time that you need to present in front of the board – um, the board will ask you a couple of questions, and then it goes from there. So whether they accept it or not… More information, exactly. Come back or go back to where your family is known. (Melody, AHW)
Feelings of ‘shame’: fear, anxiety and judgement
The AHWs extensively discussed the shame (see glossary, Appendix 1), anxiety and fear associated with oral health and accessing dental services within the community. The participants spoke about anxiety and fear arising from personal experiences or from experiencing discomfort within the dental environment. They also spoke about the stories their clients had heard within the community, from past dental care experiences of older Aboriginal Australians.
My dad’s tooth just fell out…like the whole thing. He put it in the bin. I said, why did you do that? [Unclear]. I said, why didn't you take it to the dentist, and they can put it back in? He's like, nup. My nan yells at him every day, like rips him up. She says, you can't get jobs with teeth like that you need to go and fix your teeth. (Ellie, FPW)
There's also just dental in general, the horror stories…and shame (Rachel, AHW)
Sometimes it's the elders, they instil the fear, I've got to say, because my grandmother wouldn't go into hospital. Never went to a hospital. Some of my immediate relatives could be in there dying, she won't go to a hospital. She wouldn't go and see a doctor. She wouldn't go to a dentist. God, no, she never went to a dentist. Even though my nan had false teeth, she never went to a dentist in her life. (Jennifer, management staff)
The staff also discussed that feelings of shame in the community arose from being embarrassed about their oral health or the fear of being judged.
Some people that we spoke to did this. [covers mouth with hand] Covered their mouth when they were talking to us. (Jennifer, management staff)
But also, I wouldn't initiate this story about how my parents didn't give me a toothbrush or do that, because I wouldn't want people to judge my parents. I'm sharing because it's safe. (Sharon, management staff)
I've got false teeth. Mine are through domestic violence. You know I mean? You've got to be careful on ‘em lines too. Like, I don't mind talking about it. I'm strong enough to talk about it. But there's some that don't - you know what I mean, admit to that. (Karina, FPW)
The staff discussed the effect of past government policies of assimilation that allowed for the removal of children, enforced English as the only language that could be spoken, and policed cultural practices and activities. Some participants mentioned that as a result, knowledge, language and culture were not passed down to younger generations, including the passing down of traditional dietary and dental health knowledge and practices.
Back in the day you weren’t allowed to [talk to anyone]... Doesn’t matter if you were Stolen or not. Yeah, you just weren’t allowed to. It was part of the white law at the moment. You know what I mean? (Karina, FPW)
There's certain stuff, yeah, that they chew on and stuff like that, but no ones ever really passed that down. (Karina, FPW)
Just living on bush tucker and nothing out there to hurt your teeth. (Melody, AHW)
Yeah, and this is how it went off-track and the introduction of a Western diet, and when you think about why people choose the bottle over the breast and, you know, what they put in, it's because of what's going on…and you need to capture that from Aboriginal people. Um, some of that you can see how some people do know here, and how it's okay to regain that knowledge, because the same way why other knowledge hasn't been passed down, this is, you know, the same reason. So that, I think, is really important. (Sharon, management staff)
Theme 3: Systems that provide continuity of care
Working in two worlds
The participants discussed how they found themselves balancing their professional roles while also maintaining their cultural responsibilities within the community. The staff spoke about having a role in both ‘worlds’, suggesting that the services’ policies were not always culturally safe.
Like, um, we obviously work under policies and guidelines, um - we're always competing with - what is culturally safe and appropriate versus policies that we've got [to] work under. So we're always adapting to make it work in regards to what we're allowed and what we know within ourselves as Aboriginal people what is actually appropriate to do within the homes. (Louise, AHW)
One AHW shared an example where the existing workplace policies meant that Aboriginal clients had no option to access culturally competent and affordable dental services:
Well, I have a client that's just relocated from Melbourne. She's Aboriginal, no confirmation papers, she's not on the pension card, Health Care card, and her teeth are pretty much not there. What access does she have? Any kind of money that she has - she's got five - six children now. Very young mum, 23…. It’s a brick wall. That’s just an example. (Sally, AHW)
Need for a priority dental referral pathway
All focus groups stressed the need for a priority dental referral pathway that would provide a free dental check-up for all Aboriginal pregnant women and for women who were pregnant with an Aboriginal child. This was considered an important preventative initiative for the community.
…in an ideal scenario we can get them in and get them streamlined to have that check-up then as a preventative measure for when, as you just said, pregnancy and everything. (Sarah, AHW)
Maybe that could be something, an escalated pathway so people in the program can make sure that within that - we get them checked within a... (Sharon, management staff)…Certain timeframe, like a KPI [key performance indicator] (Jennifer, management staff)
But if we offered it as something that was offered to everyone across the board, it wouldn't be so confronting… You know, so if it was something that was offered to everyone [all pregnant women with Aboriginal babies] (Sally, AHW)
Some participants suggested that there should be an initial dental appointment available to clients to raise awareness about existing oral health problems and subsequently discuss their potential risk.
Because then you go to a dentist and you find out. Because I wouldn't go unless I had an issue; then I would go (Ellie, FPW)
So I don't know how that would fit but in my ideal world once she's pregnant I think she should be able to receive some treatment, whether that be an examination and fillings or what not, what they can do during the pregnancy (Sharon, management staff)
One of the management staff recommended that Aboriginal pregnant women, mothers, and women with Aboriginal babies needed pathways to a range of public and private services, including ACCHSs.
So I think if you attach the model to your program, that could have several pathways. One into the AMS [Aboriginal medical service], because we do outreach there and we do different pathways and, you know, there's no wait for any Aboriginal child, so why can't we have that for our unborn child and mothers? And then you've got the voucher system, where if you're needing services [the AMS] can't provide, you can get a voucher…into private dental. (Sharon, management staff)
It was important that non-Aboriginal mothers of Aboriginal babies could also access culturally competent services because they were still considered part of the community.
So when we look at a holistic thing so that non-Aboriginal mum that's pregnant within our Aboriginal community, even though she's not seen as Aboriginal she's still seen as a part of our community… everyone has a place in their community, in their family structures (Louise, AHW)
Another suggestion was issuing all women with a concession card during their pregnancy to ensure that dental services were accessible to all women regardless of culture. Some participants were cautious about the potential for further discrimination if only Aboriginal women received a priority referral.
It could work from once - like from my perspective then all - well not just Aboriginal women, all women who are pregnant, there's a guideline that they have to book in before 20 weeks gestation. So, everyone is under that umbrella, who knows whether they've been booked in or not, and that's including Centrelink and everyone else…so every antenatal mum who has booked in why can't they be issued with a healthcare card for the duration for when she's pregnant? Why can't that be an open healthcare card that's given to all regardless of how much you earn and things like that? (Tess, AHW)
But how that’s rolled out, there needs to be some sort of consultation around it to be mindful about stigma that’s already attached, you know, prejudice that’s already attached…my worry would be how it’s done, done in the best way (Louise, AHW)
Theme 4: More knowledge and training to meet the local community’s needs
The AHWs and FPW recognised the importance of oral health during pregnancy for the future of healthy families and agreed that they could provide oral health education to pregnant Aboriginal women and mothers as part of their role. The participants discussed appropriate Aboriginal ways of doing in health services and highlighted the need for training in antenatal oral health. The participants also commented on their own existing oral health knowledge, practices and training received.
Understanding Aboriginal ways of doing health service provision
Participants identified that any oral health training should be integrated into an existing antenatal program. Two of the staff identified a potential role for Elders (see glossary, Appendix 1) to be involved to pass on knowledge about healthy oral health practices in families.
I think you could build it into the [antenatal] program, though. (Sharon, management staff)
I think, um, culturally we always go to our Elders for guidance so I think for the Elders to, um, have an opportunity to filter down ideas, guidance, support - that's an appropriate way for us. So I guess keeping in with that, um, you know, speak…and having that yarn and consultation with them. This is what we're thinking or what ideas do you have, can you guide us as to what will work best because the two communities are different here (Louise, AHW)
If we say something, then their grandma says something, they're not going to go say what we say – they’re going to listen to their [Elders] (Teigan, FPW)
Current oral health training, knowledge and practices
Only one AFPW had acquired oral health knowledge through formal training. All other participants across both services identified the need for a formal training program in antenatal oral health.
I think I’ve just learnt it [oral health] over the training that I’ve done, like Certificate III and IV in Aboriginal and Torres Strait Islander Primary Health Care…then over my lifetime…I know I’ve got a thing about teeth. (Melissa, FPW)
Yeah, I think informal as well. I mean, we did do little in-services. We do do in-services on dental, so it could be some formal as well…I would be up for it [formal training] (Emily, AHW)
In both services, staff 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. The FPWs also handed out dental products to families.
So I know that during pregnancy, women's oral health can be exasperated from pregnancy. You know, that can cause wobbly teeth, it can cause decay to happen quicker, so it exasperates all of the symptoms, so I do know that. Um, it can cause headaches. It can cause other health concerns. It can stop them eating. It can give them anxiety. All kinds of different things (Emily, AHW)
If the client hasn't seen a dentist in a while, we usually ask them when was their last dental check-up. (Melissa, FPW)
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...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 toothpaste and toothbrush. (Melissa, FPW)