Study Protocol: Missing Voices – Communication Difficulties after Stroke and Traumatic Brain Injury in Aboriginal Australians

Understanding the Lives of Aboriginal and Torres Strait Islander Women with Traumatic Brain Injury from Family Violence in Australia: A Qualitative Study Protocol

Globally, there is growing recognition of the connection between violence and head injuries. At present, little qualitative research exists around how surviving this experience impacts everyday life for women, particularly Aboriginal and Torres Strait Islander women. This project aims to explore the nature and context of these women's lives including living with the injury and to identify their needs and priorities during recovery. This 3-year exploratory project is being conducted across three Australian jurisdictions (Queensland, Northern Territory, and New South Wales). Qualitative interviews and discussion groups will be conducted with four key groups: Aboriginal and Torres Strait Islander women (aged 18+) who have acquired a head injury through family violence; their family members and/or carers; and hospital staff as well as government and non-government service providers who work with women who have experienced family violence. Nominated staff within community-based service providers will support the promotion of the project to women who have acquired a head injury through family violence. Hospital staff and service providers will be recruited using purposive and snowball sampling. Transcripts and fieldnotes will be analysed using narrative and descriptive phenomenological approaches. Reflection and research knowledge exchange and translation will be undertaken through service provider workshops.

Healing Right Way: study protocol for a stepped wedge cluster randomised controlled trial to enhance rehabilitation services and improve quality of life in Aboriginal Australians after brain injury

INTRODUCTION

Despite higher incidence of brain injury among Aboriginal compared with non-Aboriginal Australians, suboptimal engagement exists between rehabilitation services and Aboriginal brain injury survivors. Aboriginal patients often feel culturally insecure in hospital and navigation of services post discharge is complex. Health professionals report feeling ill-equipped working with Aboriginal patients. This study will test the impact of a research-informed culturally secure intervention model for Aboriginal people with brain injury. METHODS AND ANALYSIS: Design: Stepped wedge cluster randomised control trial design; intervention sequentially introduced at four pairs of healthcare sites across Western Australia at 26-week intervals.Recruitment: Aboriginal participants aged ≥18 years within 4 weeks of an acute stroke or traumatic brain injury.Intervention: (1) Cultural security training for hospital staff and (2) local, trial-specific, Aboriginal Brain Injury Coordinators supporting participants.Primary outcome: Quality-of-life using EuroQOL-5D-3L (European Quality of Life scale, five dimensions, three severity levels) Visual Analogue Scale score at 26 weeks post injury. Recruitment of 312 participants is estimated to detect a difference of 15 points with 80% power at the 5% significance level. A linear mixed model will be used to assess the between-condition difference.Secondary outcome measures: Modified Rankin Scale, Functional Independence Measure, Modified Caregiver Strain Index, Hospital Anxiety and Depression Scale at 12 and 26 weeks post injury, rehabilitation occasions of service received, hospital compliance with minimum care processes by 26 weeks post injury, acceptability of Intervention Package, feasibility of Aboriginal Brain Injury Coordinator role.Evaluations: An economic evaluation will determine the potential cost-effectiveness of the intervention. Process evaluation will document fidelity to study processes and capture changing contexts including barriers to intervention implementation and acceptability/feasibility of the intervention through participant questionnaires at 12 and 26 weeks.

ETHICS AND DISSEMINATION

The study has approvals from Aboriginal, university and health services human research ethics committees. Findings will be disseminated through stakeholder reports, participant workshops, peer-reviewed journal articles and conference papers.

TRIAL REGISTRATION NUMBER

ACTRN12618000139279.

Study protocol for a prospective process evaluation of a culturally secure rehabilitation programme for Aboriginal Australians after brain injury: the Healing Right Way project

INTRODUCTION

Aboriginal and Torres Strait Islander (hereafter respectfully referred to as Aboriginal) people are Australia's First Peoples, having the longest continuous culture in the world and deep spiritual connections with ancestral land. Improvements in their health and well-being is a major policy goal of Australian governments, as the legacy of colonisation and disruption of cultural practices contribute to major health challenges. Lack of culturally secure services impacts participation of Aboriginal people in health services. Aboriginal people with a brain injury typically experience poor access to rehabilitation and support following hospital discharge. 'Healing Right Way' (HRW) is a randomised control trial aiming to improve access to interdisciplinary and culturally secure rehabilitation services for Aboriginal people after brain injury in Western Australia, improve health outcomes and provide the first best practice model. This protocol is for the process evaluation of the HRW trial.

METHODS AND ANALYSIS

A prospective mixed methods process evaluation will use the Consolidated Framework for Implementation Research to evaluate implementation and intervention processes involved in HRW. Data collection includes qualitative and quantitative data from all sites during control and intervention phases, relating to three categories: (1) implementation of trial processes; (2) cultural security training; and (3) Aboriginal Brain Injury Coordinator role. Additional data elements collected from HRW will support the process evaluation regarding fidelity and intervention integrity. Iterative cross-sectional and longitudinal data synthesis will support the implementation of HRW, interpretation of findings and inform future development and implementation of culturally secure interventions for Aboriginal people.

ETHICS AND DISSEMINATION

This process evaluation was reviewed by The University of Western Australia Human Research Ethics Committee (RA/4/20/4952). Evaluation findings will be disseminated via academic mechanisms, seminars at trial sites, regional Aboriginal health forums, peak bodies for Aboriginal health organisations and the Australian Indigenous HealthInfoNet (https://healthinfonet.ecu.edu.au/).

TRIAL REGISTRATION NUMBER

ACTRN12618000139279.

"You felt like a prisoner in your own self, trapped": the experiences of Aboriginal people with acquired communication disorders

PURPOSE

Aboriginal Australians are under-represented in brain injury rehabilitation services despite a high incidence of both stroke and traumatic brain injury in this population. This study aimed to explore the experiences of Aboriginal Australian adults with acquired communication disorders (ACDs) after brain injury for the first time to inform the development of accessible and culturally secure service delivery models.

METHODS AND MATERIALS

Semi-structured interviews were undertaken with 32 Aboriginal people who had experienced a brain injury resulting in ACDs (aged 35-79 years) and 18 family members/carers across Western Australia. Thematic analysis identified common themes across participants.

RESULTS

Overall themes related to communication (both related to the communication disorder and general healthcare interactions), health and social contexts, recovery, and support, being away from family and country, knowledge and beliefs about brain injury, and follow-up.

CONCLUSIONS

An increase in healthcare staff's appreciation of the health and social contexts of Aboriginal people after brain injury is needed in order to improve communication with Aboriginal patients and the ability to offer accessible rehabilitation services. Ongoing support is required, with cultural identity noted as key to ensuring cultural security and ultimately recovery. Involvement of family and other Aboriginal people in recovery processes, as well as access to relevant Aboriginal languages and proximity to ancestral lands is central.Implications for rehabilitationAcknowledgment of cultural identity and strengths through involvement of extended family and Aboriginal Hospital Liaison Officers, access to language and proximity to country all central to rehabilitation planning for Aboriginal people after brain injury.Cultural security training for rehabilitation staff is recommended focusing on clear two-way communication skills to make medical information accessible for Aboriginal patients and to listen to patients' concerns in a way that respects cultural context.Information regarding practical support and implications for ongoing management of life after brain injury (for the person and their family) is essential, and should supplement the medical-related information provided.Follow-up post discharge from hospital best facilitated through establishing contact with local Aboriginal community through Aboriginal community controlled health services, community elders, and Aboriginal health workers across organisations.

Developing a community rehabilitation and lifestyle service for a remote indigenous community

PURPOSE

Community rehabilitation is an essential health service that is often not available to remote Australians. This paper describes the first cycle of a collaborative project, between local community members, allied health professionals and a university, to co-design a community rehabilitation and lifestyle service to support adults and older people to stay strong and age well in place.

METHODS

An action research framework was used to develop the service for adults in two remote communities, one being a discrete Aboriginal community. The first cycle involved planning for, and trialling of a service, with observations, reflections and feedback from clients, community members, university students and health service providers, to inform the subsequent service.

RESULTS

Over two years, stakeholders worked collaboratively to plan, trial, reflect and replan an allied health student-assisted community rehabilitation service. The trial identified the need for dedicated clinical and cultural supervision. During replanning, three key elements for culturally responsive care were embedded into the service: reciprocity and yarning; holistic community-wide service; and Aboriginal and Torres Strait Islander mentorship.

CONCLUSIONS

An action-research approach to co-design has led to the establishment of a unique community rehabilitation service to address disability and rehabilitation needs in two remote Australian communities.Implications for rehabilitationCo-design of community rehabilitation services between Aboriginal and Torres Strait Islander community members and the local allied health professionals can lead to development of an innovative service model for remote Aboriginal communities.Culturally responsive community rehabilitation services in Aboriginal and Torres Strait Islander communities requires holistic and community-wide perspectives of wellbeing.Incorporating Aboriginal and Torres Strait Islander ways of engaging and communicating, and leadership and mentorship for non-Indigenous allied health professionals and students are essential components for students-assisted culturally responsive services.

General practitioners' perceptions of their communication with Australian Aboriginal patients with acquired neurogenic communication disorders

OBJECTIVE

Aboriginal people have high rates of stroke and traumatic brain injury (TBI), often with residual, chronic communication deficits and multiple co-morbidities. This study examined general practitioners' (GPs') perceptions of their communication with Aboriginal patients with acquired communication disorders (ACD) after brain injury. Effective communication underpins good care but no previous research has explored this specific context.

METHODS

A qualitative descriptive approach was employed using interviews and focus groups with 23 GPs from metropolitan Perth and five regional sites in Western Australia. Data were analysed thematically.

RESULTS

GPs reported low visibility of Aboriginal patients with ACD in their practices, minimal training on neurogenic ACD, and difficulty distinguishing ACD from cultural-linguistic factors. They had few communication resources, and depended on families and Aboriginal Health Workers to assist in interactions. They rarely used formal interpreting services or referred to speech pathology. They reported communication (dis)ability having low priority in consultations.

CONCLUSION

GPs report difficulty recognising ACD and their lack of prioritising assessment and treatment of communication ability after brain injury potentially compounds the disadvantage and disempowerment experienced by many Aboriginal people.

PRACTICE IMPLICATIONS

GPs require further communication and cultural training. Improved access to speech pathology and formal interpreting services would be beneficial.

‘I’ve got to row the boat on my own, more or less’: aboriginal australian experiences of traumatic brain injury

Background:

The overarching cultural context of the brain injury survivor, particularly that related to minority peoples with a history of colonisation and discrimination, has rarely been referred to in the research literature, despite profoundly influencing a person’s recovery journey in significant ways, including access to services. This study highlights issues faced by Australian Aboriginal traumatic brain injury (TBI) survivors in terms of real-life consequences of the high incidence of TBI in this population, current treatment and long-term challenges.

Method:

A case study approach utilised qualitative interview and file review data related to five male Aboriginal TBI survivors diagnosed with acquired communication disorders. The five TBI survivors were from diverse areas of rural and remote Western Australia, aged between 19 and 48 years at the time of injury, with a range of severity.

Case Reports:

Common themes included: significant long-term life changes; short-term and long-term dislocation from family and country as medical intervention and rehabilitation were undertaken away from the person’s rural/remote home; family adjustments to the TBI including permanent re-location to a metropolitan area to be with their family member in residential care; challenges related to lack of formal rehabilitation services in rural areas; poor communication channels; poor cultural security of services; and lack of consistent follow-up.

Discussion and Conclusion:

These case reports represent some of the first documented stories of Aboriginal Australian TBI survivors. They supplement available epidemiological data and highlight different contexts for Aboriginal people after TBI, contributing to an overall profile that is relevant for rehabilitation service planning.

The Wangi (talking) project: A feasibility study of a rehabilitation model for aboriginal people with acquired communication disorders after stroke

Purpose: Aboriginal Australians are under-represented in stroke rehabilitation services and rehabilitation practices that are sensitive to the needs of Aboriginal people are not currently available. This project tested the feasibility and acceptability of a rehabilitation model and approach to therapy with Aboriginal people with acquired communication disorders post-stroke. Method: Eight Aboriginal people with acquired communication disorders post-stroke were recruited to this study. Sixteen treatment sessions were provided twice weekly at the person's place of residence by a speech-language pathologist and Aboriginal co-worker. Feasibility was measured by analysing the number of sessions conducted jointly by the speech-language pathologist and Aboriginal co-worker and participant attendance. Participant acceptability was measured through the analysis of a post-therapy questionnaire. The Aboriginal co-worker's and speech-language pathologists' perceptions of the acceptability were collected through semi structured interviews. Result: Across all sessions 84.2% were attended by the Aboriginal co-worker and speech-language pathologist and seven of the eight participants completed all prescribed sessions. Positive feedback was provided by participants, the Aboriginal co-worker and speech-language pathologist on the key components of the programme. Conclusion: The rehabilitation model used within Wangi appears to be feasible and acceptable to participants and therapists. It provides direction to improve the quality of care for Aboriginal stroke survivors.

The Transition from Hospital to Home: Protocol for a Longitudinal Study of Australian Aboriginal and Torres Strait Islander Traumatic Brain Injury (TBI)

Background: Traumatic brain injury (TBI) is a leading cause of disability in Australia. Evidence shows that multidisciplinary rehabilitation and support in the six months following TBI is important for successful independent living and social re-integration. Despite this, access to services and supports during this period is often limited by environmental, socio-economic, geographic and cultural factors. Australian studies on outcomes after brain injury have reported primarily on non-Indigenous people. This study will investigate key sentinel events during the transition from hospital to home after a TBI in the first longitudinal study with Indigenous Australians.

Method: Indigenous Australians admitted to one of three major trauma hospitals in northern Australia with a TBI, and their care givers, will be recruited. Clinical and brain injury risk factor information, along with measures of cognitive function, transition events, mental health and community re-integration will be collected at three time points prior to hospital discharge, and at three and six months post-discharge. Qualitative interviews will also be conducted. Data will be analysed using regression methods for the quantitative component, and situational analysis for the qualitative component. Annual rates of brain injury will be calculated for patients admitted to tertiary hospital facilities in the study region with a diagnosis of TBI.

Discussion: Understanding the experience and events which shape the transition period is critical to determining the services and supports that may enhance transition outcomes, and ensure that such services are culturally appropriate and endorsed by Indigenous families and communities.

Development of the Aboriginal Communication Assessment After Brain Injury (ACAABI): A screening tool for identifying acquired communication disorders in Aboriginal Australians

PURPOSE

Acquired communication disorders (ACD), following stroke and traumatic brain injury, may not be correctly identified in Aboriginal Australians due to a lack of linguistically and culturally appropriate assessment tools. Within this paper we explore key issues that were considered in the development of the Aboriginal Communication Assessment After Brain Injury (ACAABI) - a screening tool designed to assess the presence of ACD in Aboriginal populations.

METHOD

A literature review and consultation with key stakeholders were undertaken to explore directions needed to develop a new tool, based on existing tools and recommendations for future developments.

RESULT

The literature searches revealed no existing screening tool for ACD in these populations, but identified tools in the areas of cognition and social-emotional wellbeing. Articles retrieved described details of the content and style of these tools, with recommendations for the development and administration of a new tool. The findings from the interview and focus group views were consistent with the approach recommended in the literature.

CONCLUSIONS

There is a need for a screening tool for ACD to be developed but any tool must be informed by knowledge of Aboriginal language, culture and community input in order to be acceptable and valid.

Missing voices: Profile and extent of acquired communication disorders in Aboriginal and non-Aboriginal adult stroke survivors in Western Australia using linked administrative records

Background

Limited data exist on the extent of specific functional sequelae, including acquired communication disorder, among Aboriginal stroke survivors, making planning of multidisciplinary services difficult.

Aims

To obtain estimates of the extent and profile of acquired communication disorder in Aboriginal and non-Aboriginal adult stroke survivors in Western Australia and investigate potential disparities in receiving in-hospital speech pathology services among survivors with acquired communication disorder.

Methods

Stroke cases surviving their first stroke episode during 2002–2011 were identified using Western Australia-wide person-based linked hospital and mortality data, and their five-year comorbidity profiles determined. The mid-year prevalence of stroke cases with acquired communication disorder was estimated for 2011. Regression methods were used to investigate determinants of receiving speech pathology services among acquired communication disorder cases.

Results

Of 14,757 stroke survivors aged 15–79 years admitted in 2002–2011, 33% had acquired communication disorder (22% aphasia/dysphasia) and 777 (5.3%) were Aboriginal. Aboriginal patients were more likely to be younger, live remotely, and have comorbidities. A diagnosis of aphasia was more common in Aboriginal than non-Aboriginal patients 15–44 years (p = 0.003). A minimum of 107 Aboriginal and 2324 non-Aboriginal stroke patients with acquired communication disorder lived in Western Australia in 2011. Aboriginal status was not associated with receiving in-hospital speech services among acquired communication disorder patients in unadjusted or adjusted models.

Conclusions

The relative youth, geographical distribution, high comorbidity prevalence, and cultural needs of Aboriginal stroke patients with acquired communication disorder should inform appropriate service design for speech pathology and rehabilitation. Innovative models are required to address workforce issues, given low patient volumes.