Making a decision to do the hard research, that’s what discovery is about

The theme of National Reconciliation Week 2022 is Be brave. Make change. We had the opportunity to talk to Professor Cath Chamberlain when she was in Canberra for the first meeting of the NHMRC’s Principal Committee Indigenous Caucus for the 2021-2024 triennium. Professor Chamberlain is a Palawa woman of the Trawlwoolway clan (Tasmania). She is a NHMRC Career Development Fellow and also chair of NHMRC’s Electronic Cigarettes Working Committee. In her research journey, she says just deciding to commit to a research life is brave – so is committing to do the hard research.

I'd always wanted to be a midwife, since I was a teenager.

I finished grade 10 initially and then I went back as a mature aged student to matriculate. I then got into nursing through the hospital-based system. 

I did my general nursing and then I went and did pediatric critical care at Princess Margaret Hospital in Perth, and then worked in ICU in Alice Springs and got into midwifery. That was the second last midwifery course at King Edward Memorial Hospital (Perth). So, sort of lucky, I guess, getting into the last of the hospital-based courses. 

I had always wanted to go off and work in Africa. That was my dream. 

So, I took off to Africa with Médécins Sans Frontières - Doctors Without Borders - in Somalia and South Sudan and with Care Australia in Democratic Republic of Congo. That was really formative. I met and worked with traditional birth attendants and managed reproductive health programs. There was a lot of public health work as well. In South Sudan, I worked on a cholera outbreak response, we were often helping to respond to different infectious disease outbreaks. And so, I became interested in public health. 

It was shocking and quite traumatic on a number of levels but really satisfying as well. It's hard to describe how different it is, there were times I felt like I was on a Mad Max movie. But, saying that, with all those challenges, I was working with amazing people, colleagues, women, community members, and I really just learned an incredible amount.

Then I came back and got a job with the Royal Flying Doctors Service as a Flight Nurse Specialist for a couple of years, which was great, based in Kalgoorlie. It was a big catchment area and I got to do a lot of primary health care using a lot of those skills I had learnt in Africa. 

And then I managed a maternity unit in the Kimberley’s in Derby. 

Starting a research life

My husband at that time had been doing lots of fly-in-fly-out work to disaster areas and we wanted to move to the city to start a family. We had a choice really between Melbourne or Sydney, and we thought it was just a temporary thing. But here there are so many universities.  One of the things working in remote areas and in places like Africa is, you are on your own and I was often thinking, I wish I had some help with this, or could ask someone with some expertise about that. 

I was pregnant, and I thought ‘what am I going do on maternity leave’ and thought I might as well go to university. I did the Masters of International Health. It was really good to be able to take the time to reflect on women’s and children's health and build on the experiences I had had in Africa and WA. 

After the Masters, I got into the Victorian Public Health Training Scheme, which was an amazing experience. It was a training scheme they used to have at the time where after you've done your Masters of Public Health, you are basically employed with the Health Department for two years and you work on different public health projects. 

I got to work with amazing people like Professor Judith Lumley who was a real leader in women’s and children's health, she was an incredible mentor and taught me a lot and got me into research around smoking in pregnancy and thinking about how this time during pregnancy and childbirth is a time to make a difference throughout our life. 

I worked on evidence-based practice and guidelines for a few years while the kids were young, and then did my PhD on diabetes in pregnancy. I worked with Professor Sandra Eades on my PhD. A new guideline was coming out about diabetes in pregnancy and we saw that someone needed to look at the impacts of these recommendations for Aboriginal women. That was a really great learning experience with Sandra and my other supervisors.

It is that thing about ‘who's holding your ladder?’. It’s really important, particularly for women, because men do it a lot. 

Finding a research focus and opportunity for change

During my PhD, I was focused on diabetes and smoking but was also aware that there was a lot more underpinning these health issues that we're experiencing as Aboriginal people. 

The evidence of strong associations between adverse childhood experiences, trauma and poor health outcomes was becoming clearer and clearer. There was growing consensus around complex trauma and even if that wasn't named as such in a lot of the public health research articles, there were descriptions of symptoms that were very similar to what was being described in complex trauma. 

I just thought, someone really needs to look at this in relation to pregnancy care.

There are a whole lot of things that can get triggered when people become parents: past childhood experiences, coming into maternity care services can be traumatic in so many ways, and then you throw in sleep deprivation, hormones, financial insecurity, and the rest of it can be a real challenge. But despite all of that, it's the best time for recovery and that is really, really clear in the evidence that people recover more at this time in their lives than any other time. 

We know how much it's an important time for babies’ brain growth. But there’s also actually a lot of evidence and understanding about how much brain growth there is for parents as well, mums and dads.

A few people were telling us we were a little bit crazy to be tackling intergenerational trauma - how would we tackle it, it'll be too hard to do, particularly in relation to parents during pregnancy and childbirth.

But I was inspired by Professor Alex Brown who had told a few of us in a university lecture one day ‘You've got to stop just counting people dying and start tackling the really hard stuff. You're in university, you're supposed to be smart. You’ve got to be brave’.

Tackling the hard stuff: Learning to identify and support Aboriginal and Torres Strait Islander parents experiencing complex trauma

I had been lucky to be on an NHMRC early career fellowship at that time, so I had some thinking space and time to focus on preparing a proposal, which we called Healing the Past by Nurturing the Future: Learning to identify and support Aboriginal and Torres Strait Islander parents experiencing complex trauma. 

I was based at the Judith Lumley Center when we submitted Healing the Past by Nurturing the Future, working with an amazing team of investigators, including Dr Graham Gee, Professor Helen Herrman, Professor Jan Nicholson and others. 

We were wondering where to go for funding and how we were going to conduct the research. 

I know it probably doesn't sound very scientific, but I do believe in ancestors helping us. I do think our ancestors helped me a lot. 

While on my Early Career Fellowship I travelled to the United Kingdom and worked with the Center for Evidence Based Policy and Practice at University College London on an Endeavour Award. We submitted the first NHMRC proposal just before I left, and I wrote another on a train from London to Edinburgh to the Lowitja Institute for more community engagement activities at the beginning of the project. 

It was almost surreal. The week I got back I found out we were successful with the Lowitja grant and about two weeks later we found out we were successful with the NHMRC grant and it has been non-stop ever since then.

The importance of co-design in research

It has been a really incredible journey, a lot of hard work, doing co-design in three state jurisdictions.

Co-design is a bit of a buzzword – but it’s great if you can do it properly.

When we received the Healing the Past by Nurturing the Future grant it was one of only five Aboriginal CIA-led grants. It was unusual, but it was particularly unusual because it was the only one with the majority of CIs that were Aboriginal. 

We've tried to maintain that the whole way through our work. 

We started off with preliminary discussion groups with Elders like the Deadly Nannas who were just beautiful and have been supportive all the way through. One Nanna called and said ‘I've heard about your project, and I've been waiting all my life for a project like this. Can I help?’.

With codesign, we make sure that we always have Aboriginal leadership with it. We're fortunate to have lots of non-Indigenous allies that recognise how important that is to work alongside us. We always try to make sure that we have at least over 50 per cent Aboriginal investigators, Aboriginal people at our meetings, running the workshop, always presenting at the workshops, but also involved and participating. That's just really important for getting the feel of it right so that it really does feel like community co-design, that includes bringing in lots of cultural elements. 

Even from the first workshop, it was clear how important that was. We had an Elder come and provide a beautiful welcome and he ended up staying for the whole day and he was saying how great it was to see Aboriginal people up front talking, presenting, and leading in a really inclusive way. 

What is also really important with trauma is that we’re mindful of all the things that are not being said.  

Adverse childhood experience studies clearly show the impacts those experiences have on people's health long term, but also how common those experiences are. For Aboriginal people it is a particularly sensitive issue because of the risks of child protection service involvement and the removal of Aboriginal children from families. That's been the elephant in the room. 

So, one of the first things we did was develop a cultural and emotional safety framework, working with Dr Yvonne Clark.

We've ended up with a whole advocacy arm of the program that wasn't funded in the research but we just had to set it up because of the distressing things we were hearing about, for example Aboriginal Health workers being told not to tell parents that their baby is going to be taken. 

When we put in the proposals around how to identify and support parents, it became really clear in the first workshop that when we're talking about support, we also need to talk about what to do in maternity services to help parents feel safe and reduce re-traumatisation when they are coming in and having a baby; and then what sort of actual support do parents want and need. And thinking about support broadly, not in terms of clinical or psychological services, but the whole range of support that people need. 

We need to make sure that any assessment or discussions are safe, what we call safe recognition, and when we're talking about the assessment, that it needs to incorporate Aboriginal and Torres Strait Islander understandings of social emotional wellbeing and disruption of that. Looking at one of the key areas that is really important in complex trauma is relational trauma and the disruption of connectedness which is central to our wellbeing. There are more sophisticated understandings about that in our communities and we need to incorporate those into the assessment tool.  So, we've been working on our assessment tool, which we're just doing the analysis on now. 

We pre-test everything. We use an intervention mapping model, with key stakeholder workshops, and people from all states can come to the workshop. We present the findings of our previous research activities at each workshop and plan for the next research activities to co-design these strategies using a socio ecological model. 

Evaluation, implementation and scale up: Replanting the Birthing Trees

In 2020 and 2021 we put together two MRFF (Medical Research Future Fund) proposals to implement and evaluate the findings from the four-year co-design project, and final two steps of the six-step intervention mapping process.  We're now working in Morwell, piloting the implementation. We’re going there because the Victorian Aboriginal Child Care Agency asked us to go there. So, we're partnering with this childcare agency and Latrobe Hospital in Gippsland. 

The second MRFF grant is to work with NACCHO (the National Aboriginal Community Controlled Health Organisation) and other partners around building the infrastructure for scale-up. As researchers we’re looking at how we build in strong and sustainable community governance.

We’ve set it up aligned with the Closing the Gap agreement, so there's a governance committee that includes the representatives of the National Health Leadership Forum, the coalition of peaks, and they provide governance and then we become an operational body that reports to them and they provide accountability back to the community. 

We're bringing together a few people to now work on the infrastructure for scale-up, which we’ve called Replanting the Birthing Trees. We’re working with Professor Rhonda Marriot over in WA, who is someone who's been an amazing mentor for me as well. 

We’re bringing together the rich earth representing the Aboriginal knowledge, clear sky representing western research methods;  we've got the roots as the safer start, supporting Aboriginal families to stay together and prevent disruptions; the strong, sturdy trunk of the birthing tree which is around routinely implementing continuity of carer models, because all of this needs to hang off the foundation of strong relationships with caregivers; and then the branches, that's around all the support for workers, training and resources and Associate Professor Carly Atkinson is leading that work; and then we’ve for the leaves which are the bits that are always being built and replenished, including a a resource repository with things like the Baby coming you ready? app and the assessment processes and the support framework. We are setting up a framework for the range of supports that parents want, It sometimes feels like a wild ride, but it feels like it's coming together. 

What makes brave research 

I've been really grateful for NHMRC funding, my PhD was supported by an NHMRC scholarship, I received an early career fellowship which enabled me to write and lead my first successful grant, and I'm currently on a career development fellowship which has enabled me to write my second and third successful grants and build a research team. I’ve also appreciated the mentors and colleagues I’ve had along the way who have helped me take the next step.

Making a decision to do the hard research and this kind of emotionally deep research in itself, has taken a bit of bravery. And research is insecure work. At the time when I made the decision to do this, I turned down an offer of a secure teaching job. And I thought, well, this is something I've been thinking about, it might not work, I actually thought it probably won't work, I probably won't get the funding. But I've got to give it a go. 

That is what I encourage people to do; if it is something that you think is important, to try and give it a go. Because otherwise you will never know and we do have to try to address those hard things. That's the thing with research, sometimes it doesn't pan out, that's a risk. But we all feel like that at the beginning, is it going to work, and it's a bit scary that level of uncertainty. 

I also think you have to be brave to do any research, because the reason we're doing it is we don't know the answer. That is what this discovery is all about. And I think with Aboriginal and Torres Strait Islander health, in particular, we are going to need to take some more risks to do things differently. That's a strength I see in Aboriginal and Torres Strait Islander colleagues. I've just lost count of the number of times where so people come in really nervous, unsure about what they're presenting, and then presenting this stuff that just blows everyone in the room away with innovation or the way that they're thinking.