In total, 69 survey responses were received, and 19 interviews were conducted.
Survey results
The majority (n=41, 59%,) of respondents were hospital-based, 35% (n=24) community-based health facility, and 6% (n=4) community-based NGO. The main professional role of respondents was midwives (n=26, 37%), and CFHN (n=21, 30%) (Table 1).
Table 1: Professional role of survey participants
Professional role
|
Number (%)
|
Midwife
|
26 (37%)
|
Child and Family Health Nurse* (CFHN)
|
21(30%)
|
Doctor (Obstetrician/Paediatrician)
|
6 (9%)
|
Allied Health (Social Worker, Speech Therapist, Health Worker)
|
6 (9%)
|
Community Worker with Non-governmental organisation**
|
4 (6%)
|
Nurse
|
2 (3%)
|
Managers
|
2 (3%)
|
Administration
|
2 (3%)
|
TOTAL
|
69 (100%)
|
*Child and Family Health Nurses: registered nurse with postgraduate qualifications in child and family health nursing.
** Non-governmental organization (NGO): Non-profit, voluntary citizens' group that operates independently of government.
Most respondents had a good understanding of the CCW Service (Table 2); including the provision of culturally appropriate support (n=65, 94%), linking clients to supports and networks (n=63, 91%), supporting engagement with services (n=60, 87%), access to health information (n=59, 85%), and culturally responsive service provision (n=56, 83%). There was some misunderstanding that the CCWs were interpreters (n=25, 36%) and provided transport (n=7, 10%).
Table 2: Service providers perceptions of what the Cross Cultural Worker Service provides
Role
|
Number (%)
|
Culturally appropriate support to women and their families
|
65 (94%)
|
Link clients with local community supports and networks
|
63 (91%)
|
Support clients to remain engaged with services
|
60 (87%)
|
Access to health information
|
59 (85%)
|
Supports services to be culturally responsive
|
57 (82%)
|
Language specific health information
|
56 (81%)
|
Support clients to navigate health and community-based services
|
54 (78%)
|
Education, pregnancy and parenting programs
|
49 (71%)
|
Support for clients to attend appointments when referred to other services
|
41 (59%)
|
Assist clients to attend appointments
|
33 (48%)
|
Interpreter service
|
25 (36%)
|
Transport
|
7 (10%)
|
Other*
|
4 (6%)
|
* Support for psychosocial concerns and working with health professionals to develop culturally appropriate screening processes, information and insight in the area of intellectual disability/autism, not an interpreter service but do translate health information for clients as required, or not sure.
Most respondents (n=44, 64%) had referred to the CCW Service at least once, via email (n=33, 73%), in person (n=23, 52%), or by telephone (n=10, 22%). Overall, 84% of referrers were satisfied with the ease of referral. Almost three-quarters (71%, n=49) reported that the CCW Service improved integration with maternity services, however less than half (42%, n=37) said it improved child and family health service integration with 29% (n=20) unable to say. Almost two-thirds (64%, n=34) said it improved integration with community-based services, and 68% (n=46) perceived that women were satisfied with the CCW Service. Table 3 shows service provider perceptions of Service effectiveness, with most (83%) feeling it improved care for women, improved outcomes (68%), and facilitated engagement with the target communities and services (70%).
Table 3: Service providers perceptions of effectiveness of CCW Service
Service effectiveness
|
Not effective
|
Neutral
|
Effective
|
Not applicable
|
Total
|
Improved care for women
|
5 (7%)
|
6 (9%)
|
57 (83%)
|
1 (1%)
|
69 (100%)
|
Improved outcomes for women
|
5 (7%)
|
15 (22%)
|
47 (68%)
|
2 (3%)
|
69 (100%)
|
Facilitated engagement between target communities and services
|
6 (9%)
|
12 (17%)
|
48 (70%)
|
3 (4%)
|
69
(100%)
|
Collaboration with agencies in health promotion and community development initiatives
|
6 (9%)
|
14 (20%)
|
42 (61%)
|
7(10%)
|
69
(100%)
|
Interview results
The 19 interviewees comprised the 3 CCWs and 16 other service providers: 5 midwives, 4 child and family health nurses (CFHN), 3 doctors (obstetrics and gynaecology specialists/trainees), 2 NGO workers, 1 women’s health nurse, and 1 Service Manager. While CCWs are technically also service providers, their responses are reported separately to other participants to reflect their first-hand experiences of service provision and capacity to fulfil the Service aims.
Analysis identified three categories and six subcategories. The overarching theme was improved access and experience of care for women and families through the ability of the CCWs to act as “a bridge to health”. Figure 1 summarises the theme, categories, and subcategories.
Supporting access to health and community-based services
The CCW Service was seen as being pivotal in supporting access for women and families. The CCWs were well placed and able to refer women and families from migrant and refugee backgrounds to appropriate health and community-based services, and act as a bridge to health. The CCWs were able to assist with navigating services and supporting families in understanding the healthcare system, and providing culturally appropriate support.
Navigating services and understanding the healthcare system
CCW support was important to assist with accessing and navigating health services. The CCW role was viewed as extending outside health services into the community to link migrant and refugee women with appropriate community-based services, other women, and to support women in their transition to life in Australia. Service providers expressed this by saying:
It's that absolute bridge and connection in a very meaningful way. And the fact that they feel that they have somebody that they can contact at any time to help them navigate the system but it is about connecting really well with women. (Manager1)
Just to help these women who are usually all alone - they've come from a foreign country usually just with their husbands/partners. Navigating the health system is hard enough just to a person who's lived here… So, they (CCWs) take these women individually basically by the hand and navigate the health system. (Midwife2)
The CCWs also helped their clients understand how to use the health system, which was seen as critical in ensuring women were able to access care independently. For example:
I think they're probably more aware of how the system works and have a greater grasp on I guess what their expected interactions are with our clinics and a better overall knowledge of how the hospital works, but also their own health and what we can provide for them medically. (Doctor2)
Providing culturally appropriate support
The CCW role was perceived to be able to provide culturally appropriate support as they are bilingual, and have insights into how the woman is feeling due to their own cultural practices and beliefs, and lived experience of the migration and settlement journey. One midwife described this:
The CCW can bridge that gap… they have knowledge of the culture and traditions so we can see what those traditions are and then unpack them in terms of whether they are safe or not safe. (Midwife4)
Conversely, two service providers reported that one CCW for multiple cultures was viewed to be less effective than a CCW focused on a specific culture. One CFHN said:
I feel that that one culture doesn't necessarily mean that she understands all other cultures or maybe has more of a connection with another culture than any other worker would. The concept of a CCW maybe doesn't work across all cultures. (CFHN4)
Improving the healthcare experience
The second theme was about the capacity of the CCW to improve the healthcare experience. Service providers frequently used phrases such as excellent, successful project, exceptional and I don’t ever want them to go. They felt the CCW Service improved the healthcare experience by making care more personable and less frightening, which supported ongoing service engagement. The key sub-themes were in relation to communication, continuity of care and acknowledging the trusting relationships that women formed with the CCWs.
Providing continuity of care enhanced communication between service providers and women
Service providers described continuity of care (often lacking in usual service provision) provided by the CCWs as a key strength. Having one person who women can form a relationship with, and access when they need, enables them to feel more supported and confident, as described by:
I think they get access to the information that they need and I think that they have somebody that they can call. Because some people don't have anybody that gives them continuity; they have a different midwife every time they come in and I think she provides that role as being the one person you call when you’ve got a problem. And she can take them to the right areas. (Midwife3)
Enhanced communication between service providers and women was also described as being facilitated by the CCWs as they speak the language, understand the culture, and have a close relationship with the women. Two participants explained:
Sometimes it's really hard for me as the facilitator just to get them talking because they're all very shy. But I think having the CCW2 and CCW3 there… helps because they can start a conversation […] She (CCW) can start talking about what happened when she was having babies...or maybe say in their language, what I'm trying to get at. (Midwife2)
Trust in the CCW, therefore trusting the healthcare system
Service providers commented that due to the close relationship and supportive role of CCWs with the women, there is a greater level of trust in healthcare system. They felt women were able to access more services because they have formed a trusting relationship with the CCW and have a link with the healthcare system that is positive. For instance:
I think a little bit of it is definitely that sense of trust. I guess that comes from: “hey this is something I’m (CCW) recommending to you”. Like you know these people can help and support you, and then they come along … we will call an interpreter and … get help if they need it. (CFHN4)
Trust between women and the CCWs also allowed for cultural norms and practices to be explored and this trusting relationship enabled women to talk about ‘taboo’ subjects such as domestic violence, mental, sexual and reproductive health. For example:
In the domestic violence space for example a lot of people won't disclose unless it's to a trusted person. It's a really difficult conversation to have anyway, but if you have to do it outside your own language and outside people who you know, who don't understand your culture… Then without that cultural competency and way of knowing how to work with people you know it's not going to be very effective. (NGO Community Worker1)
Ultimately, service providers explained that by introducing health services and health concepts through a safe and trusted pathway, women from migrant and refugee backgrounds they felt that women feel more empowered to take control of their health at a crucial time in their lives. One doctor said:
I definitely find that my experience with the women who are labouring who have been part of the groups, they seem to be more educated about their birth and what to expect... I’m meeting them for the first time at three o'clock in the morning, and people that haven't been part of any antenatal education … struggle a lot to understand their state, what their body is going through. So, I think they (CCWs) help facilitate that kind of empowerment for the women. (Doctor1)
Organisational factors affecting CCW Service provision
The final theme relates to factors which impacted on CCW Service provision. The key sub-themes were the CCW part-time hours and capacity to fulfil role, supporting capacity building of service providers to provide culturally responsive care, and governance structures.
CCW part-time hours and capacity to fulfil role
The biggest challenge reported by service providers was that the part-time hours made it difficult for the CCWs to fulfil their role. Participants who struggled to clearly define the CCWs role called for more “regular connection”, “in-service education” or “better definition of the role.” Service providers wanted increased numbers of CCWs, increased hours, or the role to become full-time. They felt this would enhance the ability of CCWs to fulfil their role, provide more one-on-one or joint consultations with service providers, and more regular CCW engagement with service providers to raise awareness of the role. One midwife noted:
They (CCWs) only both work two days a week at the moment. I would say there's enough work for four days a week each…So, it's looking at how much work is there at the moment and how much more they could do if they had more time. (Midwife4)
The CFHNs in particular described the CCW Service as “scratching the surface’. Service providers also expressed concern for the CCWs recognising there is a great potential for CCW ‘burnout’ as they are in very high demand.
Some service providers highlighted that it would be beneficial to have the CCWs providing more one-on-one with clients, or involved in service providers consultations. All doctors wished for the CCWs to be more available in antenatal services, in contrast, CFHNs wanted the CCWs in the postnatal period. For instance:
I'd say almost the majority of our consultations are with women who are from non-English speaking backgrounds or who are from a different culture. So, we're limited in that we don't have the workers there the time that we need. (Doctor2)
The CCWs ability to fulfill their role was also perceived by service providers to be compromised by the requirement of CCWs to attend meetings, reducing their capacity to reach all women who need the Service. For example:
Well, I believe she's in a lot of meetings and I don't think you can have one person doing a role that covers a huge area, with a huge number of families, and then go: well, you need to be in meetings… I just think from a managerial point of view, I don't know how you would expect anyone to fill a job to their capacity, yet be in meetings. (CFHN3)
Supporting capacity building of service providers to provide culturally responsive care
Service providers described how the CCWs built the capacity of their colleagues by raising awareness of the CCW Service as a referral pathway that encourages and supports women to access health services. Additionally, service providers felt that the CCWs were best placed to build capacity to ensure that care is provided in a culturally sensitive way, however perceived this to be limited due to part-time hours. Service providers emphasised the need for more regular engagement with staff to ensure culturally responsive concepts were translated to day-to-day care. For example:
If the CCWs had sessions with us, the primary care providers on the coal face, because I guess my understanding comes from mostly working with Indigenous women and the training that you get around interpersonal communication, body language, what they (women) appreciate that's culturally appropriate. I haven't been given any of that information … So maybe CCWs actually spending time educating the medical, midwifery staff, capacity building. (Doctor1)
Perceptions of the CCWs themselves
CCW responses largely complemented those from broader service providers. All three CCWs described their role in supporting access and navigation to health and community-based services, improving the healthcare experience through the supportive and close relationship they formed with women, and their ability to understand cultural nuances and reflect this in care. They felt this enhanced the potential for a positive experience of settlement, and promotes social networking with other women and families. The CCWs also recognised the unique role their position inhabits, where they are advocates for the needs of women, families and their community, and providing health services that improve health outcomes. This was explained by one CCW by:
We provide information during the pregnancy and into transition into parenting and also link them to playgroup, community support or and also to provide any culturally appropriate information or education related to pregnancy and parenting. … advocating for them on behalf of them. (CCW1)
Similar to service providers, all three CCWs spoke of part-time hours reducing the capacity to fulfil their role and support capacity building of service providers. They described often feeling overwhelmed, and overloaded with their current workload. The CCWs spoke about the need to spread services more equally between antenatal and postnatal services, and one agreed with service providers regarding the need for more regular engagement with staff to describe their role and reiterate what the service can provide for women and families.
A key CCW Service strength highlighted by all CCWs was the support they received from their managers, colleagues and peers. Additionally, two CCWs described challenges in maintaining professional boundaries, especially when working in small communities. They reported that often women expected them to accept tokens of friendship, invitations to join social networks and family events, which initially the CCWs found an ethical dilemma. However, they reported clinical supervision sessions and management support enabled them to develop strategies to manage these situations in a polite and respectful way. Two of the CCWs provided examples of this:
You cannot in a small community…strictly separate professional from personal… and I've had to politely decline with the fear that they'll be offended if you don't go. (CCW3)
Sometimes when the client says "you and me have not only the professional relationship, but beyond that you know. So why don't you come to my home?" It's a bit difficult and the community is very small, everyone knows each other. (CCW2)
All three CCWs spoke of women’s reliance on them as a source of “all information”. They were very aware of their non-clinician boundaries as facilitators and information givers only. However, the CCWs described requests for immigration support, where they found it challenging to explain this to the women and families. The CCWs also spoke about service providers initial confusion with the boundaries of their role and being mistaken as a case-worker or interpreter. However, the CCWs noted that there had been significant improvements in understanding since they initially commenced in role.