Recommended methodologies to determine Australian Indigenous community members’ perceptions of their health needs: a literature review

Additional keywords: colonisation, community-based participatory research, data collection, decolonise, Indigenist, participatory action research, storytelling, yarning.

Since colonisation by British invaders, Australian Indigenous people have suffered from imposition of outsiders’ ethnocentric views of their whole-of-life circumstances. In a confidential submission to the National Inquiry into the Separation of Aboriginal and Torres Strait Islander Children from Their Families, it was stated: ‘Our life pattern was created by the government policies and are forever with me, as though an invisible anchor around my neck’ (Human Rights and Equal Opportunity Commission 1997, p. 4). It is well recognised that the detrimental effects of colonisation still affect the health and wellbeing of Indigenous people worldwide (World Health Organization, Commission on Social Determinants of Health 2007). At the International symposium on the Social Determinants of Indigenous Health (2007), it was agreed that one critical social determinant of health is the effect of colonisation, and that ‘colonisation is not simply an historical process - it is ongoing’ (World Health Organization, Commission on Social Determinants of Health 2007, p. 30).

In the research process, as a result of outsiders’ use of different frameworks and perspectives from which data is collected and interpreted, inappropriate solutions are developed (Kendall et al. 2011). When Indigenous people are resourced to collect and analyse data, a far more compelling story will be told and the emergence of genuine Indigenous self-determination in Australia will be seen (Yu 2012).

The continuing health disparities between Australian Indigenous and non-Indigenous people are alarming. Aboriginal and Torres Strait Islander people generally have poorer health outcomes than non-Indigenous Australians, with a shorter life expectancy, a higher child mortality rate and a greater burden of chronic disease (Commonwealth of Australia, Department of Health 2017). Multiple, complex factors contribute to these disparities. A combination of general factors, such as education, employment, income, socioeconomic status and health sector factors, for example, limited access to culturally appropriate services or support, contribute to these health disparities (Australian Indigenous HealthInfoNet 2017). Improving health outcomes is complex and requires acknowledgement of underlying social determinants of health and active engagement of Indigenous people to define the issues and identify solutions. One of the ways of engaging Indigenous peoples is through more involvement in research using culturally appropriate methods of data collection.

Decolonisation of the Indigenous health research agenda is necessary to improve the health outcomes of Indigenous Australians (Sherwood 2010). The United Nations supports this approach, asserting that ‘Indigenous peoples must exercise control over all research conducted within their territories, or which uses their people as subjects of study’ (United Nations 2008, p. 5). In 2018, the National Health and Medical Research Council (NHMRC) committed to ‘place a stronger focus on Aboriginal and Torres Strait Islander methodologies and approaches’ (NHMRC 2018a, p. 2). One measure of the success of their strategic framework for improving health through research would be ‘greater integration of Aboriginal and Torres Strait Islander knowledge and ways of working’ (NHMRC 2018a, p. 2).

Active involvement of Indigenous people in directing how, what and why research is conducted about them is critical because many political decisions are often made by simplistic interpretations of research data (Smylie and Adomako 2009). It is necessary to work in partnership with Indigenous people as key stakeholders throughout the research process by using culturally appropriate methods that include ethical constructs of respect; reciprocity; spirit and integrity; equality; survival and protection; and responsibility, as determined by the NHMRC guidelines (NHMRC 2018b).

Cultural determinants of health are essential to Indigenous wellbeing; they ‘encompass factors that promote resilience, foster a sense of identity and support good mental and physical health and wellbeing for individuals, families and communities’ (Commonwealth of Australia, Department of Health 2017, p. 7). Engagement in practices that maintain cultural connections is vital for self-determination and spiritual wellbeing. To address the ongoing concerns about the health of Indigenous people requires active engagement and consultation with Indigenous people. Such consultation needs to be underpinned by best practice principles of Indigenous engagement, as defined by the NHMRC (2018b) and the Australian Institute of Aboriginal and Torres Strait Islander Studies (AIATSIS) (2012) guidelines.

Culturally appropriate methods of consultation and data collection methods for all research with Indigenous people will allow the best feedback from those people and contribute to the best health outcomes. While there is great diversity in Indigenous cultural expression across Australia, the well-recognised definition of Indigenous health, as determined by the National Aboriginal Health Strategy Working Party (Commonwealth of Australia, Department of Aboriginal Affairs 1989), should inform all research approaches with Indigenous people across Australia. Australian Indigenous people view health as:

not just the physical well-being of an individual, but refers to the social, emotional and cultural well-being of the whole community in which each individual is able to achieve their full potential as a human being thereby bringing about the total well-being of their community [Commonwealth of Australia, Department of Aboriginal Affairs 1989].

‘Indigenous peoples’ holistic expressions of wellbeing … involves more than just setting health within a social determinants of health framework - it involves the larger context of country’ (Weir et al. 2011, p. 17). This literature review synthesises the literature to make it more accessible and inform change in the researchers’ practice. There are no recommendations for yarning to be conducted by an Indigenous researcher; the reviewed articles indicate that data collection by yarning was conducted by Indigenous and non-Indigenous researchers.

The Australian Journal of Primary Health was chosen because we want to advocate for Indigenous people in the research process and influence researchers in their choice of methodologies and data collection methods.

This study involved a systematic search using BioMed Central, CINAHL, Informit Health, MEDLINE Ovid, ProQuest Health and Medicine, and Scopus databases and Google Scholar. Extensive manual searches of reference lists were also undertaken. Search terms included: ‘needs assessment’ and indig* Australia* (communit* and (indigenous or aborigin* or ‘torres strait’ or islander*) and (perception* or attitude* or belief* or knowledge) and (method* or survey* or questionnaire* or yarn* or photovoice or PAR or participatory action research) and (australia* or queensland* or nsw or qld or new south wales or victoria* or vic or tasmania or northern territory or nt); Oceanic Ancestry Group; Australia.mp. and Health Science indigenous; data collection/or ‘surveys and questionnaires’; Community-Based Participatory Research/mt [Methods]; indig* and methodolog*; ‘find similar to The Yerin Dilly Bag Model of Indigenist Health Research’. A set of inclusion and exclusion criteria was applied, as shown in Table 1, to ensure the search corresponded to the aim of the review.

Table 1.  Inclusion and exclusion criteria

Due to the limited number of peer-reviewed articles relating to needs assessment in Australian Indigenous communities, search terms were modified. The scope of the review was changed to include articles that describe methodologies to enhance optimum conditions for Indigenous peoples’ engagement in the research process. Titles and journal article abstracts were reviewed by the three authors to assess relevance, followed by reading of full-texts before deciding on final articles for inclusion in the review. The primary author is Indigenous; this was important to show an Indigenous focus of the literature review.

Twelve papers met the inclusion criteria and are summarised in Table 2.

Table 2.  Summary of reviewed literature
N/A, not applicable; WA, Western Australia

Three main themes emerged from the papers reviewed: (1) the need to develop and implement Indigenist methodologies; (2) participatory action research (PAR) and community-based participatory research (CBPR) as appropriate methodologies for researching with Indigenous communities; and (3) yarning or storytelling as a culturally appropriate method of data collection. Each of these themes is detailed below.

Recognition of the traumatic effects of colonisation on Indigenous peoples and the imperative to avoid further trauma and disempowerment through the research process was a common theme throughout the literature that discusses Indigenist methodologies (Nicholls 2009; West et al. 2012; Braun et al. 2014; Doyle et al. 2017). Nicholls (2009) asserts that to evaluate empowerment and participation in a counter-colonial context critically, the researcher is essentially required to engage in political and relational layers of reflexivity. Although Indigenist research methodologies build on phenomenological, transformative and critical approaches, these approaches are still Eurocentric (Braun et al. 2014); however, by allowing Indigenist methodologies to develop independently, the inadvertent ‘colonisation’ that occurs when combining them with Western methodologies can be avoided (West et al. 2012). Data collected by colonising methods usually dismisses or negates Indigenous knowledge and ways of knowing as they are interpreted against ‘settler’ standards (Braun et al. 2014). Indigenist methodologies take research further along the path of recognising self-determination and supporting Indigenous leadership in the conceptualisation and conduct of research, and in the interpretation and dissemination of research findings (Braun et al. 2014). This methodological reform is one way of addressing the power and control struggles between the broader research community and Indigenous peoples (West et al. 2012).

Leeson et al. (2016) suggest that appreciative inquiry is uniquely positioned as arguably a decolonising agent due to the inherent privileging of positive experiences, along with inclusive and empowering possibilities of the research paradigm. A major difference between Indigenist research methodologies and the Western approach is that they flow from an Indigenous place, a community and tribal knowledge; therefore, caution is necessary in transference of results across Indigenous populations because data reflects the community in which the research was conducted and does not imply that it can be assigned to others (Lambert 2011).

Both PAR and CBPR are recommended as appropriate methods of research with Indigenous communities (Nicholls 2009; Fredericks et al. 2011; Braun et al. 2014; Doyle et al. 2017). These methods capture and incorporate the perspective(s) of the communities that are part of the research and, as such, position them as experts in their own lives and knowledges (Doyle et al. 2017). Participatory approaches aim to improve the conditions of the researched (Braun et al. 2014). Within the framework of PAR, empowerment processes and models are well situated to bring about change in individuals, organisations and communities (Fredericks et al. 2011).

CBPR has many benefits to the community engaged in the research project, as it focuses on local relevance; provides for opportunities to build on the community’s strengths and resources; fosters co-learning and capacity-building between partners; attains a balance between data generation and implementation; involves all partners in the dissemination of results; and has a greater propensity to commit to sustainability (Braun et al. 2014). Another potential benefit is the prospect of Indigenous community members being trained and actively involved as researchers. Nicholls (2009) advises that ‘researchers need to engage with reflexive evaluation of collective and negotiated design, data collection and data analysis to consider interpersonal and collective dynamics during the research process, and any effects that the research may potentially have into the future’ (p. 118). This would include data management in the event of a deceased participant.

The reviewed literature indicates that yarning or storytelling is the single most recommended data collection method with Indigenous Australians (Gorman and Toombs 2009; Bessarab and Ng’andu 2010; Fredericks et al. 2011; Lambert 2011; Geia et al. 2013; Leeson et al. 2016; Wain et al. 2016; Doyle et al. 2017; Ober 2017). The conversational method used to engage focus groups/talking circles is supported by Lambert (2011) and Braun et al. (2014). Indigenous culture is constructed through oral language and forms part of a complex culture; therefore, collecting stories of experience seems to be a valuable way of collecting data (Gorman and Toombs 2009). Geia et al. (2013) emphasise the cultural significance of yarning as a method and methodological research practice and suggest that it is ‘a very practical way to ‘close the gap’ on an individual level between the researcher and participant’ (p. 14). Leeson et al. (2016) support this, stating that given its fluidity, yarning and its focus on relationships demand researcher reciprocity, making it impossible for the researcher as an objective observer, to sit outside of the data.

In the research process, Bessarab and Ng’andu (2010) identified four distinct types of yarning with each style influencing interview quality, process and outcome:

1. Social yarning is informal, unstructured conversation in which trust usually develops; the researcher is accountable to the participant.

2. Collaborative yarning can involve sharing similar ideas; sharing research findings can lead to new discoveries and understandings.

3. Research topic yarning occurs in un/semi-structured interviews to gather information relating to the research question.

4. Therapeutic yarning occurs when the participant discloses traumatic, intensely personal or emotional information where the researcher’s role is to listen empathically; this can empower and support the participant to re-think their understanding of their experience in new and different ways (pp. 40–41).

Yarning is supportive and facilitative of both Indigenous ways of working and knowledge sharing that assists in decolonising, re-positioning and supporting Indigenous knowledges and research methods (Fredericks et al. 2011). Many contemporary Indigenous scholars use storytelling as a primary method of supporting research objectives and community goals at the same time (Lambert 2011). Yarning provides a culturally secure place and helps facilitate in-depth discussions that result in thick description (Geia et al. 2013). Wain et al. (2016) observed that yarning provided a rich source of information on personal experiences that encouraged the story provider to recognise their facilitative role in the research process. Yarning as a data collection tool constitutes a means through which Australian Indigenous ontology (the nature of being), epistemology (the nature, sources and limits of knowledge) and axiology (the nature of values and value judgements) can be prioritised in completing the research (Leeson et al. 2016). An important aspect of yarning is to allow the participant’s story to flow; where interruption by the researcher to bring the conversation ‘back on track’ can lead to missing highly pertinent information, as experienced by Bessarab and Ng’andu (2010) and Wain et al. (2016).

This literature review aimed to explore the most appropriate methodologies to determine Australian Indigenous people’s perceptions of their health needs. In her seminal work, Decolonising Methodologies: Research and Indigenous Peoples, Smith (1999) asserts:

It is surely difficult to discuss research methodology and indigenous peoples together, in the same breath, without having an analysis of imperialism, without understanding the complex ways in which the pursuit of knowledge is deeply embedded in the multiple layers of imperial and colonial practices [p. 2].

Literature that focuses on research methodologies with First Nations Peoples in North America also discusses the need to decolonise research (Kovach 2009a; Lavallée 2009; Ormiston 2010; Rowe 2014). Colonial history has disrupted the ability of Indigenous peoples to uphold knowledges by cultural methodologies; however, many Indigenous peoples recognise that for their cultural knowledge to thrive it must live in many sites, including Western education and research (Kovach 2009a). Lavallée (2009) suggests that when discussing incorporation of cultural protocols into research, a preliminary discussion of colonisation and cultural genocide and the effect that these have had on the people is necessary. ‘In keeping with the decolonising notion of an Indigenist research framework, reciprocity also includes the advancement of Indigenous ways of knowing’ (Lavallée 2009, p. 36). Ormiston (2010) agrees, stating that decolonisation is about privileging, understanding and sharing our concerns and worldviews. It is paramount for non-Indigenous researchers to recognise that the Indigenous perspective emphasises the interconnectedness of the spiritual, physical, emotional and intellectual aspects of being, whereas the Eurocentric worldview perceives these as disparate and fragmented (Ormiston 2010). Acknowledgement of this difference allows for development of new methodologies that honour Indigenous ways of knowing, being and doing.

It is necessary to develop research approaches that challenge the ongoing colonisation of Indigenous peoples, communities and knowledges, and achieve cultural proficiency by ensuring concordance or congruence between the core values of the research, researcher, and researched (Doyle et al. 2017). It has been suggested that the theoretical framework preferred by Australia’s Indigenous people is critical theory; a radicalised epistemology in that it is overtly political in intention, it fits the agenda of a liberatory epistemology and advocates for those most oppressed in society (West et al. 2012). The concept of Dadirri, as explained by West et al. (2012), is a practice of deep listening and acceptance which, in the context of research, is a method that enables working with Indigenous people and allowing their voices to be heard.

In the past, most research was conducted ‘on’ rather than ‘with’ Indigenous people. To counter the negative effects of the power imbalance, Indigenous epistemologies and axiologies have informed the undertaking of participatory and collaborative research (Nicholls 2009). Both PAR and CBPR methodologies provide opportunities for Indigenous people to be actively involved in the research process, with inherent benefits to individuals and the community. Engagement of an Indigenous Reference Group (IRG) to guide the researchers in culturally appropriate protocols, behaviours, language and interpretation of data will strengthen the validity of the research process and findings. Wain et al. (2016) found that the IRG provided an interface between the epistemological differences and created a foundation from which the Aboriginal narrative resources could be generated, guaranteeing they were true to, and respectful of, Indigenous cultures.

Engaging with Indigenous people in the research process requires sophisticated levels of communication. The reviewed literature situates yarning or storytelling as the most appropriate method of engagement, as it fosters a level of trust and reciprocity in a relaxed manner (Gorman and Toombs 2009; Bessarab and Ng’andu 2010; Fredericks et al. 2011; Lambert 2011; Geia et al. 2013; Leeson et al. 2016; Wain et al. 2016; Doyle et al. 2017; Ober 2017). Similar data collection methods are discussed in research with other Indigenous populations internationally, including Botswana, Canada and North, Central, South and Latin America, which support talking/sharing circles, storytelling and conversation as appropriate data collection methods (Bessarab and Ng’andu 2010; Lavallée 2009; Kovach 2009a; Kovach 2009b; Kovach 2010; Iseke 2013; Summers 2013; Caxaj 2015).

Unique characteristics distinguish yarning or storytelling from other forms of qualitative data collection methods. Yarning or storytelling is an informal, relaxed discussion whereby the researcher gleans answers to research questions, whereas narrative inquiry is more structured to answer specific research questions with the researcher describing the narrator’s story. Conversation, a non-structured method of gathering knowledge, is more than an interview because it combines reflection, story and dialogue (Kovach 2009b). Storytelling, an ancient practice used by Indigenous persons/cultures, is integral to Indigenous learning within the different spheres of life (Lambert 2011; Geia et al. 2013). Ober (2017) concurs, explaining that storytelling is a natural part of life used to inform past histories, kinship structures, beliefs, values, morals, expected behaviour and attitudes. As a method of gathering knowledge based on oral storytelling tradition congruent with an Indigenous paradigm, the conversational method is of significance to Indigenist methodologies (Kovach 2010). Summers (2013) supports this view, stating that personal experiential knowledge is viewed as a sacred expression in Indigenous research and storytelling, and is to be respected as a valid form of data collection that does not require citations for it to be legitimised as an Indigenist methodology.

Bessarab and Ng’andu (2010) and Wain et al. (2016) found that the use of yarning or storytelling required more time for the research process than initially planned. Data collection and transcription from recordings were more extensive. In deference to cultural considerations, it is necessary for researchers and funding bodies to factor in potential delays, particularly for research projects in remote Indigenous communities, for the conduct of ceremonies, Sorry Camp, kinship responsibilities, caring for Country and other matters. One of the principles defined by AIATSIS (2012) states that researchers need to recognise that Indigenous individuals or communities may have more pressing priorities that may impinge on the research time frames. Another factor that may impact on the research process that must be taken into account is gender issues. Bessarab and Ng’andu (2010) found that gender, an issue that is always present, can emerge at different times during an interview where it can challenge, confront, distract and place the researcher in an awkward situation.

The literature search process was conducted rigorously; however, it is possible that some articles that relate to the literature review question may have been missed. Nevertheless, from the papers that were reviewed, there was consistency in the themes that emerged associated with appropriate methodologies and approaches used in Indigenous research.

The imperative to decolonise research methodologies is evident from the reviewed literature. Acknowledgement and incorporation of Indigenous ontologies, epistemologies and axiologies is essential to this process. Cultural differences between Indigenous people across Australia imply that each location may have their own ways of knowing, being and doing, which will underlie their preferred methods and methodology for the conduct of research. Paramount to the Indigenous research process are consultation, participation and ownership of data, which inherently belongs to the research participants. Primarily, the research is to be for the benefit of the Indigenous people, so it is right and proper for research processes to be culturally appropriate.

Traditionally and contemporarily, Indigenous peoples’ principal method of communication is grounded in oral traditions with cultural knowledge, including history and social values, passed on through the generations. This review of the literature demonstrated that yarning or storytelling is the single most recommended data collection method in which to engage with Indigenous people. Yarning and storytelling allow for a reciprocal relationship between participant and researcher that can elicit in-depth information pertinent to the research question/s. The results of the reviewed literature are likely to have applications for Australian Indigenous people living in urban, rural and remote communities.

Indigenist methodologies are steeped in ancient history and must be respected for their intrinsic value in all phases of research projects to enable self-determination for Australian Indigenous people to be realised.

The authors declare no conflicts of interest.