Miilwarranha (opening): introducing the Which Way? study

Australian Aboriginal peoples are the oldest living culture in the world, with Euro‐Western academic research and science currently dating a continuing connection to Country at over 75 000 years. ¹ Aboriginal and Torres Strait Islander birthing practices have been critical to the oldest living culture, comprising a living discipline with origins that predate Euro‐Western medicine by millennia and continue to foster environments for Aboriginal and Torres Strait Islander peoples to thrive. ² However, the ongoing nature of colonisation, associated policies and systemic racism ³ continue to impact Aboriginal and Torres Strait Islander peoples today, including maternal and child health outcomes. ⁴ One factor contributing to this is smoking, which has been systematically embedded through colonisation. Colonisers used tobacco to exploit Aboriginal and Torres Strait Islander peoples’ labour and services, providing tobacco as payment in lieu of wages and in rations until the late 1960s. This entrenched smoking among Aboriginal and Torres Strait Islander peoples. ⁵ The mechanics of colonisation also increase exposure to the basic causes or drivers of tobacco use, including economic and educational exclusion. ⁶ Such racialised inequities result in Aboriginal and Torres Strait Islander smoking during pregnancy being over three times higher than among their non‐Indigenous counterparts. ⁵ Identifying culturally safe and acceptable strategies that increase effectiveness for Aboriginal and Torres Strait Islander women to quit smoking are urgently required. However, appropriate evidence to inform smoking cessation care, particularly during pregnancy, drawn from Indigenous peoples is scarce. Evidence included in this MJA supplement aims to privilege Aboriginal and Torres Strait Islander women in the development of Indigenous‐led evidence on smoking cessation care. ⁷ , ⁸

Most health care providers have and will continue to encounter Aboriginal and Torres Strait Islander peoples in their daily practice. As such, identifying respectful and effective strategies that resonate with Aboriginal and Torres Strait Islander peoples to quit tobacco use, particularly during pregnancy, through health care systems are required.

Researchers and clinicians have conducted qualitative, ⁹ , ¹⁰ , ¹¹ , ¹² , ¹³ quantitative ¹⁴ , ¹⁵ , ¹⁶ and pilot trials ¹⁷ , ¹⁸ , ¹⁹ and one randomised trial ²⁰ to develop an evidence base to address the disproportionate smoking rates experienced by Aboriginal and Torres Strait Islander women during pregnancy. All trials have incorporated health provider smoking cessation training and resources for women and health providers and offered nicotine replacement therapy to pregnant women who we unable to quit unaided. ¹⁷ , ¹⁸ , ¹⁹ , ²⁰ Two included peer support groups and financial incentives. ¹⁸ , ¹⁹ One considered the wider social and economic context of smoking in pregnancy and tailored supports to incorporate broader support services for women. ¹⁹ However, to date no trial has been able to report effective strategies to empower smoke‐free pregnancies and the evidence base is still lacking.

Research and evaluation are particularly important to better tailor supports for Aboriginal and Torres Strait Islander peoples, especially given the diverse language, social and nation groups. Research has the potential to quantify the nature and characteristics of smoking in pregnancy and what types of smoking cessation supports resonate with Aboriginal and Torres Strait Islander women. ²¹ Generally, data from diverse nation groups across Australia report smoking characteristics as a binary outcome (yes/no). However, our previous research reports that Aboriginal and Torres Strait Islander women are making multiple quit attempts during pregnancy, ²² with national data commonly failing to accurately detail such nuance in the quitting journey that can be critical to guiding best practice. Given the lack of Indigenous‐specific evidence and the substantial room for improvement in health outcomes, the Which Way? study, reported in this supplement of the MJA, ⁷ , ⁸ aims to address an urgent need to better understand smoking, for and by Aboriginal and Torres Strait Islander women, using community‐led research questions informed through an Indigenous lens. ²³ In the words of Linda Tuhiwai Smith:

When Indigenous peoples become the researchers and not merely the researched, the activity of research is transformed. Questions are framed differently, priorities are ranked differently, problems are defined differently, people participate on different terms. ²⁴

The foundations of Which Way? are derived from Aboriginal and Torres Strait Islander‐led research which recognised that Aboriginal and Torres Strait Islander women want to quit smoking and are interested in non‐pharmacological options to be smoke‐free. ²² The project aims to build an Indigenous‐led evidence base for culturally responsive smoking cessation care and to inform policymakers and health service providers on how improvements can be made to the health and wellbeing of Aboriginal and Torres Strait Islander mothers and babies.

Which Way? is a culturally responsive, co‐designed and co‐owned study with urban and regional Aboriginal communities in New South Wales. ²⁵ The study is consistent with the United Nations Declaration on the Rights of Indigenous Peoples, ²⁶ the World Health Organization Framework Convention on Tobacco Control, ²⁷ and the updated Aboriginal Health and Medical Research Council guidelines for ethical research with communities. ²⁸ This national cross‐sectional survey was developed through collaborative, community‐driven processes with partnering communities to understand community‐led research questions, address current knowledge gaps, and refine content and questions for relevance, cultural acceptability and sensitivities. This process was iterative and completed during COVID‐19 lockdowns. The survey was developed and then approved by community partners, and included pilot testing with 15 Aboriginal women known to the research team before going live.

Recruitment methods

Online recruitment for research of this sensitive nature was not common research practice in Aboriginal and Torres Strait Islander health research at the time of recruitment, but we recognise that COVID‐19 has also driven significant changes in innovative recruitment processes. As such, establishing trust and rapport, and highlighting social accountability in this research was critical. All Aboriginal community partners shared posts recruiting participants in the study. Sharing of posts was also supported by peak bodies, such as the National Aboriginal Community Controlled Health Organisation. The project also utilised paid advertisement and sharing via community pages such as Tiddas for Tiddas, to increase reach and provide the opportunity to participate, particularly for Aboriginal and Torres Strait Islander women who did not use or follow an Aboriginal health service.

Analysis and reporting

Indigenous governance and meaningful engagement of Aboriginal and Torres Strait Islander peoples informed the analysis and reporting but was embedded from conception to reporting the study findings, consistent with the United Nations Declaration on the Rights of Indigenous Peoples and the Framework Convention on Tobacco Control. Australia is a party to the Framework Convention on Tobacco Control, which details the need for Aboriginal and Torres Strait Islander peoples to be engaged in the development, implementation and evaluation of tobacco control programs.

The analysis and reporting process privileged Aboriginal and Torres Strait Islander voices, knowledges and experiences, particularly communities as the knowledge holders, to address the health and wellbeing of their peoples. In facilitating meaningful analysis and interpretation, an iterative analysis process was undertaken in partnership with community partners and guided by an Indigenous‐led analysis team.

Preliminary findings were initially exported using REDCap electronic data capture software, and summarised for community partners. Lead researcher (MK) provided presentations to community partners for response and direction, including prioritising analysis in an iterative process. All analysis plans were driven by community partners’ questions, and only community relevant factors were reported. Shifting from problem‐based to solution‐focused Aboriginal and Torres Strait Islander‐led tobacco control enacts Indigenous sovereignty to be ultimately free from nicotine dependence and related death and disease. In the words of Walter and Anderson:

From an Indigenous ontology the more important question is not what differences exist, but why? A reversing of the ontological lens would compel different questions in a different research agenda. ²³

Ethics and dissemination

The Which Way? project upholds the prioritisation of the CONSIDER statement ²⁹ and acknowledges the need for transparency of research practice (Box).

Box 1. The CONSIDER statement ²⁹ .

Governance: The community governance committee oversees all aspects of the research, guiding and strengthening the research process and ensuring all conducted research is held accountable. This means the research is Aboriginal‐led, Aboriginal‐owned, and upholds the prioritisation of Aboriginal communities.

Prioritisation: Strong community partnerships are developed and sustained through ongoing respect, consultation and appropriate dissemination of research and continued transparency with all communities. The research priorities are built on community strengths, interests, and worldviews. Development of lasting relationships with partnered community services and engagement of staff and community at all services ensures research aims address specific community priorities.

Methodology: The research acknowledges the importance of building on gulbanha (knowledge), to ensure the research is relevant and meaningful to improving the health and wellbeing of Aboriginal and Torres Strait Islander peoples. Indigenous knowledges are the processes and the outcome of the research.

Participation: The seeking of individual and community consent is imperative to mitigate the burden placed upon both the individual and the communities involved in the research. This upholds Indigenous data sovereignty, and ensures the safety and security of participants remains unidentified throughout the research.

Capacity: Guidance and mentorship is woven through the research process at every level. Capacity building is enabled through the mentorship of two Aboriginal and Torres Strait Islander medical students working as research assistants throughout the research. Through respectful relationships with partnering communities, 360° learning and knowledge sharing is offered, to build capacity within the academy in Indigenous and wellbeing, as well as in the health sector with diverse community health needs, research design and implementation, knowledge translation, and health promotion. This is reflected through, but not limited to, authorship opportunities and governance committee membership.

Analysis and interpretation: Aboriginal and Torres Strait Islander communities direct the analysis and interpretation that is then undertaken by an Indigenous‐led team.

Dissemination: Accountability of the research is upheld through monthly updates and consultation with partnering services, governance committees and communities. Ongoing translation plans are co‐developed with the research team, governing bodies and community partners to appropriately acknowledge the wisdom, leadership and expertise of partnering communities in developing an Indigenous‐led evidence base for smoking cessation care. Outcomes of this research have been presented through a range of webinars with peak bodies (Cancer Institute NSW, the Aboriginal Health and Medical Research Council, the Victorian Aboriginal Community Controlled Health Organisation). We have also developed infographics for community to share, and have developed and conducted workshops for Tackling Indigenous Smoking teams nationally.

Conclusion

The Which Way? study reported in this MJA supplement highlights the need to embed culturally safe care, including cessation supports, into everyday practice. The study also provides an example of how research in Aboriginal and Torres Strait Islander contexts can be undertaken in a “good way”, with Aboriginal and Torres Strait Islander communities.

Open access

Open access publishing facilitated by The University of Newcastle, as part of the Wiley ‐ The University of Newcastle agreement via the Council of Australian University Librarians.

Competing interests

No relevant disclosures.

Provenance

Commissioned; externally peer reviewed.