Participatory Action Research
While the wider CAN project had determined that a PAR approach was required for each phase, (8), the approach and details for the Aboriginal arm of the project were still to be determined. As with the wider project, PAR was selected as the preferred collaborative approach because, from the participants’ perspective, it enabled deeper understanding of the research problem in order to find appropriate and responsive action-oriented solutions (9).
As HS began to explore possible approaches to the research, she became aware of the need to incorporate the diverse voices of local Aboriginal community members. Through conversation and reading, she had discovered that Aboriginal people had a more holistic view of life and connectedness within their communities, with nature and their country or land (10). She realised that she would need to go beyond Western interpretations of PAR in order to respond to the advice of her mentor and the AWP, and Indigenous Research ethics guidelines.
HS sought to create a research approach underpinned by Aboriginal values and culture that was reciprocal and involved transparent knowledge sharing. She felt it was essential to truly consult with the local Aboriginal people about their needs and priorities, then present their opinions in their own voices, without the filter of her or other researchers’ assumptions. The research process began with consultations in the form of “Yarning”, which involves a free-flowing, uninhibited conversation and deep listening in an environment in which (the intention was) all participants felt safe and respected (11). Yarning promoted active participation and interaction, strengthened partnerships, communication, responsibility and accountability; it created a space where the whole team and community members were able to face ongoing challenges together. Using Yarning principles, respectful and collaborative approaches to data collection, interpretation and categorisation of findings were made possible, enabling the best opportunity for potential application of realistically implementable, on-the-ground solutions (12)
Learning about and understanding the importance of ‘Dadirri’ (deep listening): Establishing trust
The next step involved gaining an understanding of the importance and process of deep listening. ‘Dadirri’ (13) is an Aboriginal word meaning inner, deep, quiet listening and a profound awareness of the “deep spring of sentience that comes from within” (14). In simpler terms, Dadirri means patient listening with understanding to enhance real communication, which is the heart of conversation. Dadirri encourages transparency about who we are and what we hope to achieve, and in research, what benefit research brings and for whom (15). Dadirri recognises that individuals who are more ‘comfortable’ with each other build mutual trust, and exchange information more effectively than individuals who have less contact or are less at ease. West et al. (2012) observed that Dadirri brings peace, understanding and increased awareness. Thus, Dadirri enables an unbiased, trusting and respectful relationship to be built and maintained.
Dadirri is a concept that the Ngangikurungkurr (river people) from Daly River in the Northern Territory of Australia have chosen to share. Dr Ungunmerr-Baumann, an Elder of Daly River who was also the Principal of Daly River School, explains that Aboriginal people have endured learning the Western way and listening to what Western people say for many years, and while much of this was acceptable, some was obligatory; Aboriginal people were forced to listen. She said, “We still wait for fellow Australians to take time to know Aboriginal people and to be still and to listen to us” (16). She insisted that listening and learning must go both ways; Aboriginal and Western knowledge must come together without one ruling the other. Reflecting deeply on her words, HS acknowledged that it was important to recognise and respect Aboriginal knowledge and incorporate it into the development and enacting of the methodology.
HS realised that the fundamental elements of Dadirri, of mutually respectful interpersonal and social interactions, were important due to the past and ongoing impact of colonisation; from initial invasion, to Stolen Generations when Aboriginal children were forcibly removed from their families(14), to ongoing marginalisation and racism. HS discovered that not a single Aboriginal family she spoke to was untouched by the impact of these events, with resulting mental health and alcohol and drug implications; all shared these stories. Knowing this history was essential to understanding the unique spiritual and cultural attributes, and the challenges many Aboriginal people experienced. These challenges, however, remain misunderstood and unrecognised by the majority of non-Aboriginal people (17). In order to do no harm, and to avoid colonising assumptions and trends within this research project, it was important to first listen deeply and attentively.
Dadirri encourages recognition of the uniqueness and diversity each individual brings to a community, and the importance of this diversity within a ‘whole’ community. It considers ways of relating and acting ‘within’ community. There is an emphasis on the process of contemplation with an in-depth understanding and awareness of one’s ‘thoughts, words and deeds’, from within and without (18); of not rushing into things but waiting for the right time to do them with care (19). Deep listening is non-intrusive, reflective and non-judgemental. It considers what is and what is not being said. It is a responsible process of purposeful planning to act, based on learning, listening and being informed by wisdom and knowledge (20). It is non-judgemental watching and listening from the heart and ears before acting in good faith (18). Profound deep listening creates knowledge; and when people’s experiences are heard and acknowledged, it also brings healing. In this way, researchers who work with Aboriginal people using Dadirri are encouraged to venture beyond their basic academic responsibility of being ‘just an investigator’ and instead to work with Aboriginal people as co-researchers with the potential for enhanced wellbeing and healing.
‘ Ganma’: knowledge sharing
Participatory Action Research (PAR) is a useful framework to bring research processes together; PAR can assist researchers to focus on real issues that affect real people by clarifying how things happen, and how the people concerned perceive their situation, infer the need for change and respond by taking action (21). It creates a process where people who are confronted with similar issues identify and reflect on their experiences to find an effective solution (22). PAR has the potential to improve outcomes for the wider community through community members’ involvement in the research design and action (23). Therefore, PAR is a systemic approach to investigation that enables people to consider and find effective solutions to problems that they (and their communities) confront in their everyday lives (24). But how was HS to bring all of the voices and viewpoints together? How was she, a non-Indigenous international PhD student, to write a truly comprehensive research report and a thesis that honoured the many voices and perspectives she was hearing? For inspiration, she turned to another Indigenous cross-cultural concept called ‘Ganma’.
The Yolgnu people from Arnhem Land in the Northern Territory of Australia describe Ganma as respectful two-way sharing of cultural knowledge and interaction between Aboriginal and non-Aboriginal people (Yunupingu & Watson, 1986, in Muller, 2012). Ganma refers to both a naturally occurring phenomenon involving two river systems on Yolgnu lands, and a way to improve relationships between Aboriginal people and non-Aboriginal people (25). Aboriginal knowledge’ represents water from the river (fresh water), and ‘Western knowledge’ (non-Aboriginal knowledge) represents water from the sea (salt water). When these waters run together at an interface they mix with each other to form a foam that is the creation of new knowledge generated from the interaction and collaboration of Aboriginal and Western knowledge (26). By sharing their cultural understanding of Ganma, Aboriginal people have also shared how Aboriginal and Western peoples and knowledges can collaborate while maintaining their separate identities.
Ganma describes the context of collaboration, interaction and knowledge-sharing phenomena whereby each person is mindful of the other’s individual and combined experiences, and their contribution to the collaboration (Yunupingu& Watson, 1986, in Muller, 2012). It provides the pathway for connecting people and bringing them to actively work together to create new knowledge that is not claimed as ‘mine’ or ‘yours’, but as ‘ours’ (27). The process of knowledge-sharing and interaction has memory; forgetting people’s history can lead to losing one’s identity (28). The foam retains individual particles of both fresh water and salt water, which continue to carry their own identities and memory. The Yolgnu people explain that if the foam (knowledge) is cupped roughly in the hands, it evaporates; it must be held gently to reveal its true nature. It is also necessary to be quiet and patient, and to listen deeply to hear the foam’s soft sound (28). In this way, Ganma is closely linked to Dadirri.
HS reflected that similarly, ACW and members of the local AWP had explained to her that for people to understand and work with Aboriginal ways of living and culture, they need to ‘work with sheer good heart (understanding), mind (attitude) and hands (skill) to render sharing hands to walk together’ (Field Journal, 2012), respecting the integrity of both Aboriginal and non-Aboriginal cultures (27).
When HS took these concepts back to ACW and AWP members for discussion, all identified that linking PAR with Ganma was justified and respectful. Although this knowledge sharing concept originated on the other side of Australia, the key elements of Ganma resonated with their own cultural understandings and philosophy. There was recognition that combining Ganma and PAR would enable a cross-cultural community development approach that recognised the importance of local Aboriginal people identifying and defining the problem requiring research; it would also prevent external researchers from working in isolation from the community (29).
Community Development Concepts
Further discussion identified that this new PAR-Ganma approach could enable deeper exploration of the complex situations that were occurring for Aboriginal peoples in relation to MH and AOD morbidities. This provided potential for the health and wellbeing of the local community to improve through involvement in research; if their stories were heard, and their knowledge was respectfully incorporated, the results could inform culturally safe and responsive improvements in service provision. The suburbs where this research was situated are recognised as having significant socioeconomic disadvantage. Combining PAR with Ganma could help to describe the landscape of social and economic arrangements, as well as cultural implications, to identify why ‘health for all’ is not always possible for all community groups within capitalist societies (17). The Ganma-PAR process also had the potential to bring together the knowledge and experiences of consumers and MH-AOD comorbidity service providers, enabling a more balanced understanding of the realities of health issues and health service responses. Potentially this process could also assist service providers to critically analyse their service provision and take appropriate action to improve their services in response to community information and feedback.
Self-determination, critical theory and partnerships
As part of her PhD learning process, HS continued to review literature about what constituted good Aboriginal health research and critically reflected on the extent to which she was able to incorporate these concepts into the project. She increasingly understood that Aboriginal people’s battle against oppression influenced their evaluation of whether a research activity was justifiable and respectful, or colonising. She read key influential authors who had identified ways to incorporate self-determination into Aboriginal research processes within South Australia. Indigenous scholar Rigney (1999) proposed three main principles of Aboriginal research as being emancipation, political integrity and privileging Aboriginal people’s voices. He argued that critical theory concurs with an Aboriginal view of the ‘just world’, promoting recognition of self-determination and attempting to affirm the individual and the community through political freedom and sociocultural liberation.
Non-Indigenous researchers de Crespigny, Emden (30) described a Partnership model for ethical Indigenous research that provided a culturally-safe, holistic, ethically-sound Aboriginal research approach with four key features for creating collaborative engagement with Aboriginal people; ‘Respect’, ‘Collaboration’, ‘Active Participation’ and ‘Meeting Needs’ (30). This Partnership Model recognised the need for flexibility, reciprocity (benefit in return) and mutual obligation, recognising that at times community members needed to attend to community responsibilities before research responsibilities. These concepts linked closely to the ethical guidelines for Aboriginal research (7, 30).
Including Key Stakeholders
Collectively HS, ACW, the AWP members and the wider CAN research team also recognised the importance of involving other key stakeholders during the development of the research project to ensure engagement, support and participation (21). Making meaningful changes in MH-AOD comorbidity service delivery required inclusion of a diverse range of knowledges – those of government and non-government service providers, clinicians, managers, coordinators and support services – and their roles. Working relationships needed to be built and maintained. HS began meeting with different people and groups providing co-morbidity services and support services, building relationships and inviting suggestions for the project. This process of inclusion began with the ethics approval process and continued through all phases of the research.
HS identified critical theory as the most appropriate approach for this action-oriented project because critical theory encourages the questioning of power, socio political and economic ideologies. In particular, Habermas, a second-generation critical theorist, introduced the idea of emancipation through mutual understanding, appropriate communication and critical reflection (31). Crotty suggested that critical research could uncover hidden domination and oppression, and enable exposure and analysis of power systems, thus contributing to liberation through change (32). Freire (33) argued that marginalised people’s wisdom and knowledge is the best resource for achieving realistic solutions to the issues they encounter in everyday life. This resonates with processes of self-determination that give voice to Aboriginal people, rather than having others talking on their behalf (34). Critical theory promotes liberation and identifies and challenges power structures (35). As such, HS recognised that it could encourage consumers and service providers to look deeply into the service provision system to analyse consumer utilisation, satisfaction and benefit. It had the potential to support Aboriginal people’s self-empowered action for transformative change in their health status. Using critical theory as a basis could even possibly enable a greater conscious awareness of political structures within the health care system and existing barriers to care, thus enabling structural and service modifications to meet community needs.
HS and the research team also used post-colonial theory as described by Smith (2001) to shape the methodology. Post-colonial theory identifies the importance of recognising that colonisation is ongoing and continues to impact negatively on people’s lives, health, well-being and social determinants of health, and acts to disempower them (rather than assuming that Australia is in a post-colonial period where the effects of colonisation are no longer felt). Smith identified that the ongoing impact of colonisation is an important reason why Indigenous peoples distrust Western research. Therefore, any research involving Indigenous peoples must be de-colonising in intent, highly accountable, focus on self-determination and involve deep critical reflection by non-Indigenous researchers. Post-colonial theory reinforces the importance of examining underlying structures of power, historic institutionalisation and different forms of oppression (14). A decision was made collaboratively by HS, ACW, AWP members, the CAN team and supervisors at the AWP meeting to predominantly use critical theory as the overarching theory for this comorbidity study, but to look very deeply at the grassroots level using Dadirri and Ganma to understand the primary causes of power imbalances linked to colonisation and how these impacted on MH and AOD comorbidity care access.
Collectively, the concepts Yarning, Dadirri, Ganma, community development, self-determination, partnership, critical theory and post-colonial theory were brought together to inform and develop an approach to PAR most appropriate for exploring and potentially improving MH and AOD comorbidity services with, and for, Aboriginal peoples. It was anticipated that this approach would enable Aboriginal community members’ full engagement with the research process, integration of their knowledge and approaches, and inbuilt flexibility and sustainability that respected their needs in terms of fulfilling their cultural responsibilities. Importantly, it also had the potential to accelerate the shift towards local Aboriginal community members being recognised as accountable partners, advisors and advocates in research.