Insiders as outsiders: Bicultural research assistants describe their participation in the evaluation of an antenatal clinic for women from refugee backgrounds

Abstract

Refugee populations are widely regarded as difficult to access for research purposes, often because of specific ethical sensitivities and practical challenges. Hence, research methods must be judiciously chosen and fine-tuned to ensure they are sufficiently sensitive and culturally appropriate. Bicultural Research Assistants, who typically share language and cultural similarities with respondents, may be gainfully employed to help address these challenges. By assuming a cultural ‘brokerage’ role, they are well positioned to advise the research team, helping to ensure culturally appropriate conduct throughout the study. Despite extensive use of participatory methods in qualitative studies, the experiences of Bicultural Research Assistants in research activities in tertiary hospital environments, particularly maternity care settings, are rarely reported. This paper addresses a deficit in the literature on this topic. It describes the roles and insights of five female Bicultural Research Assistants trained in basic research methods, and employed on an evaluation of a specialist antenatal clinic for women from refugee backgrounds. Their inclusion as members of the evaluation team was essential to successfully engaging (male) gatekeepers, recruiting eligible women, administering surveys, and conducting, transcribing, and translating interviews. Following the evaluation, the Bicultural Research Assistants contributed a one-off Focus group which explored their motivations for participating in the evaluation, and their experiences of occupying multiple roles as co-researchers, interpreters and respondents. Reported benefits included the acquisition of new skills, improved interprofessional relationships and greater acknowledgement of their roles and responsibilities by hospital staff and community stakeholders. Gender-related barriers were also described. Customary socio-cultural norms, which positioned women as relatively powerless and subservient, were frequently contravened by the Bicultural Research Assistants in their research roles.

Keywords

Refugees culture empowerment thematic analysis interprofessional working participatory research maternal antenatal

Background

Refugees and other immigrants, including asylum seekers and those displaced by war and political instability, have typically suffered, or feared, persecution, discrimination and gross violations of their human rights. Hence, their health and social care needs are multifactorial and complex. Whilst lack of access to sexual and reproductive health and social care services is an acknowledged barrier to improving selected maternal outcomes (Janssens et al., 2006), referrals may be hindered by professionals who lack the expertise to recognise symptoms and initiate timely and appropriate treatment (Smith, 2006). Problems are likely to be compounded when health and social care providers fail to appreciate limits, or actual gaps, in their knowledge and skills, and when services are ill-equipped to meet the needs of these vulnerable groups. As we elaborate in the following section, research agendas frequently fail to include non-mainstream populations. This is possibly because taking account of their particular, and often complex, needs has potentially significant resource implications which may make funding applications uncompetitive. In a period of ongoing fiscal uncertainty, increasing academic pressure and job insecurity, and the ever more onerous requirements needed to secure research Ethics and Governance approvals, it is perhaps unsurprising that researchers regard inclusive approaches as simply ‘too hard’ and the outputs insufficiently generalisable.

Researching ‘marginalised’ populations

Difficulties with accessing and recruiting respondents are commonly experienced aspects of the qualitative inquiry and are widely acknowledged by researchers (Karnieli-Miller et al., 2009). Accessing ‘hard to reach’ populations (Abrams, 2010) poses particular issues in research with immigrants and refugees due to population-specific sensitivities and ethical challenges such as the requirement to obtain ‘genuinely informed consent’ (Mackenzie et al., 2007: 300). The appointment of Bicultural Research Assistants (BRAs), who share language and cultural similarities with respondents, is an important mitigating factor in this respect. Bicultural (or peer) researchers can provide an essential ‘brokerage’ or ‘navigator’ role throughout the research enterprise (Henderson and Kendall, 2011; Johnson et al., 2009), helping to ensure all members of the research team are conversant with the protocols for engagement with the selected communities. The rationale and theoretical basis for enlisting BRAs (or equivalent personnel) in research activities with ‘hard to reach’ populations may be further explained with reference to the well-established ‘insider/outsider’ literature (Brannick and Coghlan, 2007; Sixsmith et al., 2003). ‘Insiders’ are well informed about the target population, who perceive them as credible and trustworthy; they are also knowledgeable about the identity and influence of gatekeepers, and some possess highly developed negotiating skills.

Bicultural colleagues and research activities

The contribution of BRAs as interpreters in studies where respondents and researchers do not share a common language has been previously acknowledged, as has their role as active agents in co-producing research accounts (Temple and Edwards, 2002). Qualitative researchers generally accept that interpreting and translation processes are neither neutral nor objective, but rather that meanings are actively co-produced (Temple et al., 2006). Hence, interpreters cannot be regarded as mere technicians; as ‘transmitters of neutral messages across languages’ (Temple, 2002: 847), focused solely on generating a factually ‘correct’ response and unconcerned about the broader dimensions of their roles and responsibilities (Wallin and Ahlström, 2006). To the contrary, excellence in cross-cultural research demands that translators take account of their individual and social positioning and worldviews (Wong and Poon, 2010), and make visible their inevitable, but not always acknowledged, human biases which are inseparable from the ‘doing’ of research.

Reproductive health outcomes for women from refugee backgrounds

Women from refugee backgrounds have often endured sustained abuse and exploitation, including culturally normative (albeit increasingly criminalised¹) practices such as Female Genital Mutilation (FGM), otherwise known as ‘Cutting’ and/or forced marriage² (Refugee Council, 2009). Research confirms that pregnancy and childbirth predisposes some refugee and immigrant women to worse pregnancy outcomes, including more preterm births and stillbirths (Confidential Enquiry into Maternal and Child Health, 2008; Small et al., 2008). The overall effect of migration, however, is best regarded as equivocal, with some groups showing similar, or improved, outcomes compared with the receiving country, and others moving in the opposite direction (Gissler et al., 2009, Merry et al., 2013). Perinatal mental health is also generally poorer for immigrant and refugee women compared to their native born peers (Collins et al., 2011), although tools routinely applied to assess perinatal mental health status are not without problems when applied to culturally and linguistically diverse groups (Stapleton et al., 2013b).

Poorer reproductive health outcomes, including those pertaining to childbearing events, are linked to high parity and closely spaced pregnancies (Harris et al., 2006), complications arising from unsafe abortions (UNHCR, 1999) and the sequelae of culturally specific practices including FGM (Okonofua et al., 2002; Straus et al., 2009). Low-level educational attainment, often a direct consequence of cultural norms in women’s countries of origin which limit or entirely prohibit their access to formal education,³ restricts opportunities to acquire the requisite (English) language skills known to assist resettlement and integration processes in the receiving country (Deacon and Sullivan, 2009). Specifically, it poses an additional, and often insurmountable, barrier to immigrant women accessing and receiving appropriate reproductive health and social care.

Maternal and infant health outcomes may also be influenced by the cultural competency of maternity service providers. Ethnocentric attitudes are known to negatively affect immigrant women’s maternity experiences (Murray et al., 2010), whilst care which is perceived as ‘hostile and unforgiving of cultural differences’ (Allotey et al., 2004: 12) together with institutional discrimination, and/or racism, act as additional deterrents (Waugh, 2010). The quality of interpreter provision further impacts on women’s willingness to access maternity care (Carolan and Cassar, 2007), although evidence suggests that establishing a relationship of trust with a care provider may be more important than mere accuracy of translation (Robb and Greenhalgh, 2006). Inadequate/non-existent facilities for children, transport difficulties and inflexible clinic opening hours are cited as explanations for women attending scheduled appointments late, or failing to attend altogether (Murphy Lawless and Kennedy, 2000; Stapleton et al., 2013a). Poor quality information about the maternity care system, including relevant diagnostic tests and procedures, and models of available care presented in a format and language accessible by the target population, is also problematic (Gaudion and Allotey, 2008).

BRAs, research roles and responsibilities

The involvement of BRAs in research activities may vary considerably from undertaking discrete tasks, such as interpreting and translating, to full engagement as partners sharing in all aspects of the project from design to implementation and analysis, as advocated by proponents of Participatory Action Research (van der Velde et al., 2009). Unless their inclusion is carefully planned, however, with potential benefits clearly articulated and agreed by all parties from the outset, participation in the research enterprise may be little more than tokenistic. Hence, the need for safeguards to prevent against the exploitation and/or silencing of contributions from BRAs, especially if these contradict mainstream views (Turner, 2010).

The five female BRAs employed in this study were themselves from refugee backgrounds; their mother tongues reflected their countries of origin (Sudan, Somalia, Afghanistan and Rwanda), which in turn represented the five main languages spoken by women attending the antenatal clinic (Sudanese Arabic, Somali, Kirundi, Dari and Hazaragi). Establishing and maintaining a high degree of ‘correspondence’ between researcher and researched was an important principle in our study, as earlier research in this area suggested it was associated with a greater sense of partnership and improved patient satisfaction (Cooper et al., 2002).

Unfortunately, we were unable to secure the necessary resources to involve the BRAs in all aspects of the evaluation, nor for the entire duration. However, funding was sufficient to train and employ them to: recruit respondents, organise and facilitate survey completion and Focus Groups (FGs), undertake translating and transcribing activities, and participate in research-related meetings. In addition to an hourly rate of pay, they were also reimbursed for all additional research-related activities including travel costs and (mobile) phone use, and for their time participating in the FG on which this paper is based.

Design and methods

The data for this paper were generated from a single FG with the BRAs following their employment on a large, mixed methods evaluation of a specialist antenatal clinic attended by women from refugee backgrounds (Stapleton et al., 2013a). The clinic, located in an Australian tertiary maternity hospital where approximately 5000 public patients give birth annually, is staffed by female personnel including a midwife, social worker and obstetrician. Continuity of care is offered throughout the antenatal period.

An intensive one-day workshop, facilitated by a recognised trainer and expert in the field of refugee health, inducted the BRAs in basic research skills, including administering surveys and facilitating FG interviews. Research activities required the BRAs to translate and/or interpret as the majority of respondents did not speak adequate English. The trainer stimulated discussion through role-play whereby the BRAs enacted scenarios they could expect to encounter, such as ensuring respondents understood the information sufficiently well to provide informed consent, and managing uncooperative behaviours from gatekeepers. Pair work exercises following role-play activities increased the BRAs confidence and readiness to commence fieldwork. The BRAs were shown how to complete a daily field diary, which included details about all aspects of their research-related activities, especially those concerned with interactions between stakeholders and potential respondents. The training workshop evaluated extremely well, with all participants rating their learning experiences as having exceeded their expectations.

The BRAs recruited eligible women, where necessary negotiating access through the (male) head of the household and/or community. They then arranged mutually acceptable times and locations to administer surveys and undertake FGs. Three months after completing the evaluation, the BRAs were invited to participate in a FG to discuss their experiences, which is the focus of this paper. Although all five women agreed to participate, in the event only four were consented as one was unable to attend on the day, due to a family emergency. Three months was considered sufficient time for the BRAs to critically reflect on their involvement, to consider the advantages and disadvantages, and possible role conflicts with respect to assisting with, and participating in, research processes. The discussion, which lasted approximately 90 minutes, was in English, digitally recorded and transcribed verbatim. The transcript was independently coded by two of the authors (1, 2); key themes were identified and verified, following which thematic analysis was performed (Attride-Stirling, 2001; Mason, 2008). In keeping with the traditions of qualitative enquiry, quotations remain in original language used by the BRAs, who are ‘anonymised’ by country to facilitate distinctions between cultures.

Hospital Human Research Ethics approval was granted for all aspects of the study.

Size and scale in research design: The case for small datasets

Critics might argue that a one-off FG with four respondents does not constitute a sufficiently robust dataset, at least for the purpose of critical analysis. We refute any such assertion, and contend that representation, especially of and by individuals/groups that tend to be marginalised by mainstream processes, is intrinsically linked to the qualitative endeavour, and especially to notions of empowerment and emancipation. In this respect, we endorse the ‘small is never too small’ sentiments of researchers who do not disregard their reporting responsibilities on the basis of (small) respondent numbers alone, but who seek instead to extend the possibilities for understanding how research methods operate differently according to group size, constitution and orientation (Toner, 2009). We also wish to emphasise that the BRAs were all mothers themselves, had used the hospital maternity service, and/or the specialist refugee clinic (established in 2008), and had accrued considerable research experience throughout the period of the clinic evaluation (12 months). Most were also trained interpreters and others had obtained professional qualifications in their countries of origin. Hence, we considered their testimonies could illuminate important, and often unacknowledged, aspects of research activities.

In the following section, we report on three main themes which emerged from analysis of the FG discussion: (i) Entering and navigating the research arena; (ii) Acquiring and incorporating new skills; and (iii) Occupational challenges and solutions.

Findings and discussion

Entering and navigating the research arena

The BRAs all reported feeling anxious about how women and their families would respond to them in their research roles. Whilst most had worked as professional interpreters in both hospital and community settings, they worried about not being received positively within the social milieu of domestic settings. Although respondents were offered a choice of venue (including the hospital or a local community-based option) for completing surveys and participating in FG discussions, all expressed a preference to remain in their homes. All members of the research team concurred with the BRAs that women’s homes afforded the most conducive environment, especially regarding privacy and provision for the requisite food-related rituals. In the event, women and their families welcomed and accepted the BRAs and the research agenda, even on the occasions when although they shared a common language, they were from different cultures:

They’re all welcoming (…) they are co-operative with me. Even those who are not from my culture. (Sudanese BRA)

Despite lengthy, and repeated, explanations, the BRAs frequently reported considerable difficulty persuading respondents to leave domestic chores and engage in conversation about their experiences of maternity care from staff working in the specialist antenatal clinic. Visiting women’s homes in an official capacity required acknowledgement of the normal conventions associated with receiving guests. Preparing and serving food was an important aspect of this ritual, and although normally readily accepted by the BRAs in a social setting, it was a source of frustration in their research roles:

I would just be saying (to the respondent), Oh no, no, no, you come here (…) I don’t want a tea, don’t make a tea, I’m in a big rush. I’m going and I was, three hours I was there (laughs). (Afghani BRA)

Whilst experienced social scientists may be only too aware that time scarcity and deadline pressures are taken-for-granted aspects of contemporary research, the intensity of these demands was a new, and at times unwelcome, source of stress for the BRAs. Recruitment and data collection processes required that they observe and negotiate, traditional customs and practices, including those associated with hospitality. Social etiquette demanded that visitors to the household were properly welcomed, while the rules of reciprocation required that guests respond appropriately by making polite conversation and accepting refreshments that were offered. If they wished to avoid provoking anger, the BRAs were obliged to accept the hospitality offered:

(Respondents) are going to make tea, and you say, don’t (…) I don’t want a tea (…) then they get angry. (Burundi BRA)

Rejection of these socio-cultural norms implied insult, which the BRAs worried could result in them being denied future access, and hence the opportunity for enrolling women into the study. Failure to comply with behavioural norms also risked generating tensions in household relations, resulting in husbands imposing sanctions on their wives, including withdrawing permission for them to participate in the research. The more Westernised BRAs sometimes struggled with the need to honour traditional conventions, especially those governing gender relations. They also appreciated, however, the need to avoid provoking feelings of shame and inadequacy in respondents, and any sense that they were not fulfilling their traditional feminine roles. This was an important consideration for women who were typically defined by their roles as wives and mothers.

The BRAs made frequent reference to difficulties they encountered trying to access respondents’ voices directly. The training they had received emphasised the importance of obtaining information ‘legitimately’ through first-hand accounts from women who had used the refugee clinic, rather than ‘second hand’ interpretations through an intermediary, such as a husband.

However, our training package failed to anticipate the problems, this would present to BRAs who were working within social contexts' where women’s opinions were typically either not sought, or were disregarded. Thus, we failed to anticipate the degree to which cultural norms would direct respondents’ husbands to exercise agency on behalf of their wives.

Before I was going (to the respondent’s home) I was ringing and just saying, I’m coming at this time (…) I want to talk to you. But again I was finding their husbands sitting next to me. (…) Every time (…) the men was sitting with me. (Afghani BRA)

Cultural norms also generally proscribed women from doing ‘business’ unaccompanied (by husbands). Hence, the BRAs either had to tolerate the presence of a husband, and his wife’s relative silence, or devise creative and acceptable strategies that avoided conflict and did not cause embarrassment. The BRAs described how they became very adept at quickly masking any irritation they may have felt when they were met at the door by a woman's husband. They reported being mindful of the need to engage in social chat and tea drinking rituals with men in the household, to never disagree with their opinions, and to avoid initiating, or continuing conversations which could potentially turn acrimonious.

Getting ‘words from the woman’ was problematic for all BRAs, but perhaps most difficult for those working with newly arrived women who were not well acculturated, and those from more conservative cultures where gender divisions were strongly protected and/or reinforced through sanctions. The BRAs who were well assimilated into Australian society, and had adopted more egalitarian models of spousal relations, complained about what they perceived as outdated and oppressive attitudes.

The majority of the BRAs occupied community ‘activist’ and/or professional interpreting roles and hence most had access to information about incidents involving respondents, the details of which had not necessarily been disclosed by the individual concerned. Conflicts arose when the BRA was aware of facts which were important for the purpose of the evaluation (such as a respondent receiving poor service, or mistreatment by a maternity professional) but which the respondent herself did not mention during the course of an interview.

Quite a few of them (respondents) got very, not good, behaviour from the midwife (…) but they were not saying these things to me. (…) I’m not allowed to put the things, put my word in their mouth. (Afghani BRA)

The difficulty the BRA is articulating here – how best to assist a respondent to articulate her thoughts – is a conundrum which social scientists, and indeed clinicians, regularly encounter. It was, however, a new challenge for the BRAs, not least because in their customary roles as interpreters, they were primarily required to translate verbatim, rather than probe for alternative, contextual, meanings or indeed, to encourage women to reflect on their experiences, and to evaluate them critically.

Acquiring and incorporating new skills

This section focuses on the reflections offered by the BRAs on the new skills they acquired as a result of working on the evaluation. The project emphasised the benefits of working cross-culturally in a research environment, and engaging with refugee women and families from other communities.

Yeah for me I really learn a lot. Each time I go to a new family, I get a new experience. I’ve not only worked with my community, I’ve worked with the other community, not from even my country. (Sudanese BRA)

The insights the BRAs gained from respondents about contemporary maternity service provision in a tertiary Australian setting broadened, and/or updated, their own knowledge, which helped to ensure that information they disseminated to newly arrived expectant mothers was current and individually relevant. Newly arrived refugee women, including those who were pregnant and/or mothers of small children, were able to take advantage of the well-established personal and social networks enjoyed by the BRAs, thus easing their adjustment into a new and unfamiliar life. In this respect, the BRAs were widely perceived as cultural ambassadors, with rights of access and other privileges which they were able to exploit in their research roles. A strong sense of engagement in the research project, including an appreciation of their role as co-constructors of new knowledges, fuelled the BRAs understanding of ‘doing good’ by their respondents (Bell, 2013; Peled, 2010). Indeed, we gradually came to see these factors as central and motivating influences, which informed the BRAs initial decisions to become involved in the evaluation and to see it through to completion.

Learning new skills required diplomacy, time and patience. For example, accessing respondents’ critical commentary required the BRAs to establish rapport and offer the necessary reassurances that any feedback received would be valued and highly regarded by the research team. Concepts such as confidentiality, which were familiar to the BRAs in the area of clinical interpreting, were rather more nuanced in the research setting; explaining anonymity added an additional layer of difficulty to the BRAs exchanges with respondents and their families.

They (respondents) were a bit anxious […] it (critical feedback) would get to the people that are treating us […] I was satisfying them but […] that little scary part […] it’s going to go to them (service providers) and they were a bit mindful of their words. […] It was taking me 40 – 45 minutes to 1 hour to satisfy them that nothing will happen to you in the future if you give birth at the (hospital) […] your information won’t come in front […] but they would say no, no don’t write these things. (Afghani BRA)

Despite reassurances, respondents feared that commentary might be negatively received, bringing shame on their families and communities and prejudicing their future access to health and social care services.

An increased sense of self-confidence was another widely reported ‘spin-off’ from the BRA role. This was unsurprising as the job required BRAs to be self-starters: to take the initiative with identifying and contacting eligible respondents; making (and remaking) appointments; negotiating access to women’s homes and organising travel arrangements to complete surveys and undertake interviews. Although the BRAs were used to working with a diverse range of clients in a variety of health and social care settings, ‘inter-reacting’ with research respondents and their families in skilful ways within domestic environments was reported as a novel, and ongoing, learning experience.

To me that is really, really good experience to have, give me another skill of inter-reacting with people and yeah, overcome that fear (Sudanese BRA).

The acquisition of new skills was a powerful incentive that both stimulated and challenged the BRAs, maintaining their interest over the duration of the evaluation.

Occupational challenges and solutions

Managing the demands of a research agenda which operated in accordance with a ‘Western’ timeframe was a widely reported challenge. In comparison with rather more elastic notions of time observed by the communities the BRAs represented, the norms of the health service environment and research processes were generally perceived as rigid and unyielding. In these arenas, where time equals money and individual outputs are quantifiable signifiers of efficiency and productivity, the BRAs struggled with juggling the pressures to meet recruitment and data collection targets, with role obligations which required they be socially available to respondents and their families. In the following excerpt, the Burundi BRA explains that no matter how often she visits, or for what purpose, she would always be received as ‘family’ and must therefore fulfil the attendant obligations before ‘digressing’ to discuss her research agenda:

My community, they all know me (…) so they will think, Oh I’m just visiting them (…) Oh, I want to talk to mum, then dad. (Afghani BRA)

Despite repeated advance phone calls to agree a time and a place to meet, and lengthy explanations about the purpose of the visit, the BRAs efforts to generate the data they sought were nonetheless often thwarted:

You ring, then you say that this time I’m coming, and are you happy with the time? And they said yes. And I ask, are you at home? And she say, yes. (…) One family I went and I had to wait for nearly one hour, because she wasn’t there. (…) People tell me, I’m coming soon, I’m coming soon, then they’re not (coming). But I have to wait yeah, because we working with the community. You have to be patient. (Sudanese BRA)

Distracting any children present in the household was another recurring, and time-consuming, aspect of research for which the BRAs had no option but to assume responsibility in order to access the mother. This not only incurred further delays but also sometimes left the BRAs without essential tools:

And then they have two or three (children) at home (…) And I’ve lost all the pens, the packet of pens that I’ve got, every time, I was just giving the pens to the children to quieten them … distract them. (Burundi BRA)

Exhausting one’s personal supply of pens would not normally be a problem as the researcher might reasonably expect a replacement to be readily available from within the household. However, the BRAs were usually working in poorly equipped domestic environments, many of which were often completely devoid of non-essential goods and materials; hence pens (and notebooks) were prized by parents and children alike.

Despite setbacks, the BRAs proved adept at multi-tasking as they simultaneously translated and interpreted, maintained field diaries and kept logbooks with details of phone calls, appointments, and expenses incurred in relation to their research activities. Although the research team frequently reminded the BRAs that lapses in maintaining fieldnote entries were inevitable, and that additions could be made at any time, the BRAs reported feeling a sense of personal failure on the few occasions they were unable to complete records contemporaneously. Follow-up phone calls to clarify information with respondents were widely reported:

When I get home I found that I forget something to ask and I ring again (…) I needed to call them and get more information. (Burundi PRA)

Rather late in the evaluation, we discovered that one reason for fieldnotes and other records not being completed immediately following an episode of data collection was because the BRAs were anxious to demonstrate English language competency in their written entries. This required some to seek information from dictionaries and the Internet, clarification from their children and trusted family members, and making additions and alterations to draft copy, before submitting a final copy. The research team had not appreciated the additional pressures and workload this created for the BRAs, whose everyday jobs as interpreters and community workers did not normally require them to provide such hard evidence of their English literacy standards.

Conclusion

Findings from our service evaluation (Stapleton 2013a) strongly suggested that BRAs are essential whenever a recruitment strategy seeks to include populations who do not share a language in common with the research team. This is particularly the case for research in the health and social care arenas where such populations are typically amongst the most disadvantaged and suffer the poorest health outcomes; mothers from refugee backgrounds and their babies are noteworthy examples. The successful employment of BRAs from discrete language and cultural groups provides a framework for employing bicultural workers across maternity and related hospital settings. Our experience also suggests that the focus on difference through participation in research activities may be an important, albeit incidental, vehicle for staff cultural awareness training. This is particularly so for dominant majority groups such as service providers who may struggle to attend formal training sessions on account of working part-time or night shifts.

Gendered cultural norms in respondents’ communities generally proscribed the (female) BRAs from doing ‘business’ if they were unaccompanied (by a male). Hence, they either had to accommodate a husband’s presence, and his wife’s relative silence, or devise creative and acceptable strategies such as making conversational openings for the husband to articulate his views, and confirming, rather than contradicting, opposing viewpoints. These measures helped to avoid conflict and minimised the potential for embarrassment; saving ‘face’ was an important facilitatory tactic which the BRAs regularly employed. Getting ‘words from the woman’ was problematic for all BRAs, but perhaps most difficult for those working with respondents who were newly arrived in Australia, and/or from conservative cultures with rigid and strongly protected gender roles, typically reinforced through sanctions. Despite the constraints which worked against their unrestricted access, and which the BRAs were concerned would negatively impact on data quality, their employment on the evaluation provided a conduit for the voices of some of the most marginalised women to be heard, and hence to inform changes to future service delivery.

Careful consideration must be given to recruiting BRAs to ensure they are sufficiently experienced and mature for the role. Whilst ‘insiders’ may be instrumental in the production of high quality data, this cannot be assumed, as pre-existing allegiances may result in conflicting loyalties and bi-partisan tensions, with unacknowledged bias contaminating research processes. Although highly resource-intensive, individualised and ongoing support which is responsive to changing needs must be freely available and adequately budgeted for throughout the duration of the research project. We initially underestimated the time the BRAs needed for initial negotiation and dissemination of project-related information, and the need for repeat visits to secure access and undertake consent processes. These issues have obvious budgetary implications. We also failed to anticipate the degree to which the BRAs would feel pressured by the (tight) timeframe set by the research agenda and the imperative of funding requirements. Hence, the BRAs reported feeling burdened by the pressure of our expectations to complete tasks as quickly as possible and to constantly demonstrate efficiency and productivity.

Investment in training and appropriately timed follow-up ensured the BRAs were conversant with key aspects of research processes, which enabled them to embrace their roles effectively and confidently from the outset. Generating good quality data is hugely time-consuming, even for experienced researchers not facing language barriers and differences in socio-cultural norms. At debriefing sessions, the BRAs regularly commented that working alongside experienced researchers provided them with insights into many of the taken-for-granted aspects of their cultures. As we have noted, one such feature was the concept of time. Although the BRAs were accustomed to navigating different understandings of Western and non-Western notions of time, they were nonetheless surprised by the time-consuming nature of the research enterprise. Most struggled to find a balance which allowed them to achieve their research targets without causing offence to respondents and their families, or indeed without neglecting the needs of their own families and wider communities.

The research team did not initially appreciate the degree to which the BRAs would be linguistically challenged by the demands of the research agenda and the need for additional English language and literacy support. The qualitative component of the evaluation was particularly confronting in this respect. Although this oversight was remedied part-way through the study, we acknowledge that without access to trusted relatives with good English skills, BRAs might experience varying degrees of difficulty compiling fieldnotes and translating interview data.

A recurring difficulty all the BRAs encountered was how to present the concept of critical feedback to respondents, and that any such commentary would be treated confidentially. Convincing respondents that their accounts of deficiencies in the maternity service were not only welcomed but they would serve as important catalysts for future improvements in provision, was a difficult concept to convey. The BRAs struggled with how best to persuade respondents that their criticisms were not only wanted but that they would be positively valued and would not negatively impact on any future contact they, or their families, might have with health and social care services. Bringing shame on a husband, for example by complaining about aspects of treatment provided by officially appointed employees of the host country, was to be avoided at all cost. When initially invited to describe their experiences of accessing the specialist maternity clinic, then, almost all respondents expressed only praise and gratitude. Whilst this was understandable, and largely accounted for by respondents’ low expectations of maternity care based on previous experiences in their countries of origin, the BRAs worked hard to make respondents aware that gratitude alone could not advance service provision. Sufficient time must therefore be built into training programs to familiarise BRAs with novel concepts, so that they are able to find culturally acceptable and practical solutions to the problems they encounter.

The acquisition of new skills and insights was an important incentive to the BRAs. It helped them maintain momentum and interest in the evaluation and served as transferable ‘capital’ in their interpreting roles and their community development work. We suggest the model employed in our evaluation, as described in this paper, may be a useful template for adaptation across other maternity and related settings, not least because interpreting and translating are integral aspects of research processes for respondents who do not share a language in common with the research team. Done well, cross-cultural research provides coherent and credible narratives that help to explain the beliefs and values of culturally different ‘others’. It also stimulates ongoing service reform, helping to ensure that provision is appropriate, user-friendly and responsive to need.

Implications for practice

The research team were extremely fortunate in recruiting and working alongside a group of BRAs who not only greatly expanded our intellectual and cultural horizons but who were also consistently reliable, and highly productive, co-workers. All members of the research team contributed to developing the collegial relationships which we believe were essential to completing the evaluation in a timely manner and to producing findings of significance which were well received by all stakeholders. We suggest this model of cooperative endeavour enables a diverse skill set which is both appreciated and may be gainfully exploited for the ongoing development of all professionals’, and the service in which they work.

Future research might usefully focus on the multiple, and highly nuanced, ways in which power operates in research settings which involve minority groups. We suggest this would enable more inclusive research agendas to be set, which take account of the particular needs of ‘marginalised’ groups. This approach might also provide the impetus needed to identify additional barriers which currently hinder collaborative working arrangements within research teams.

Footnotes

Acknowledgements

The authors thank everyone who contributed to the evaluation, including the women, hospital staff, external stakeholders and the project reference group. They specially thank the Bicultural Research Assistants, whose input ensured that the views and experiences of women unable to speak English were articulated. They also thank both of the reviewers for their thoughtful and critical comments which undoubtedly improved the paper.

Funding

The Brisbane congregation of the Sisters of Mercy funded the original Evaluation on which this paper is based.

Declaration of conflicting interests

There are no conflicting interests, financial or otherwise, for any of the authors.

Notes

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